Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
Please note the Local Coverage Determination, L34519, and Local Coverage Article, A58917, the Plan used in 
their decision to deny services is not binding in this case. The rules do not have jurisdiction where the services 
were provided. 
 
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 one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that a panel of genes is a distinct procedural service from a series of individual genes. All 
services billed to Medicare must be reasonable and necessary. As such, if a provider or supplier submits a 
claim for a panel, then the patients medical record must reflect that the panel was reasonable and necessary. 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. You can find this rule in the Local Coverage Article for the Billing and Coding of Molecular Diagnostics 
(MolDX): for the Testing of Multiple Genes, A58120. 
 
 
 
 The rules say that the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation 
Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when the 
patient has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and not been 
previously tested with the same test using NGS for the same cancer genetic content, and decided to seek further 
cancer treatment (e.g., therapeutic chemotherapy). You can find this information in the Centers for Medicare 
and Medicaid Services, Internet-Only Manual, Publication 100-03, National Coverage Determinations Manual, 
Section 90.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that OIVIT does 
not improve health outcomes in Medicare beneficiaries. Therefore, CMS determines that OIVIT is not 
reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act. Services 
comprising of an OIVIT regimen are nationally non-covered under Medicare when furnished pursuant to an 
OIVIT regimen. You can find this rule in the Centers for Medicare and Medicaid Service, Internet-Only 
Manual, Publication 100-03, National Coverage Determination (NCD) - Outpatient Intravenous Insulin 
Treatment (40.7). 
 
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 gradient compression stockings (such as code A6530) are an example of a wound care item 
which is non-covered under the surgical dressing benefit because it does not meet the statutory definition of a 
dressing (not all-inclusive). This dressing is non-covered under the surgical dressing benefit. You can find this 
information in the Local Coverage Article for Surgical Dressings - Policy Article (A54563). 
 
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 modifier 59 is used to identify procedures/services, other than E/M services, that are not 
normally reported together, but are appropriate under the circumstances. Documentation must support a 
different session, different procedure or surgery, different site or organ system, separate incision/excision, 
separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or 
performed on the same day by the same individual. However, when another already established modifier is 
appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the 
use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not 
be appended to an E/M service. You can find this rule in the Centers for Medicare and Medicaid Services, 
National Correct Coding Initiative Policy Manual, Chapter 1 (E). 
 
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 following individual Tier 2 genetic tests are unlikely to impact therapeutic decision-
making, directly impact treatment, outcome and/or clinical management in the care of the beneficiary and will 
be denied as not medically necessary: 81403. You can find this rule in Local Coverage Article Billing and 
Coding: Molecular Pathology Procedures A56199. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that Medicare pays for medically necessary ambulance transport services. Medicare makes 
separate payment for paramedic intercept services only when they are furnished: 
 
1. in a rural area, 
2. by a provider that is under a contract with 1 or more volunteer ambulance services. You can find this rule at 
42 CFR Section 410.40(d). 
 
The rules say that for the purposes of Paramedic Intercept coverage, an area is a rural area if: 
 It is designated as a rural area by any law or regulation of a State; 
 It is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan 
Area (NECMA); or 
 It is located in a rural census tract of an MSA as determined under the most recent Goldsmith 
modification. 
 
Presently, only the State of New York meets these requirements. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 15, Section 20.1.4(a)(5). 
 
The rules say that for claims with dates of service on or after January 1, 2001, providers must report revenue 
code 540 and one of the following Healthcare Common Procedure Coding System (HCPCS) codes for each 
ambulance trip provided during the billing period: A0426; A0427; A0428; A0429; A0430; A0431; A0432; 
A0433; or A0434. In addition, all providers report one of the following mileage HCPCS codes: A0380; A0390; 
A0435; or A0436. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 30.2 
 
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 if the ambulance is called/dispatched but the beneficiary dies on the scene prior to the 
arrival of the ambulance: Payment may be made for BLS service if a ground vehicle is dispatched or at the 
fixed wing or rotary wing base rate, as applicable, if an air ambulance is dispatched. Neither mileage nor a rural 
adjustment would be paid. Providers or suppliers report the A0428 (BLS) non-emergency or A0429 (BLS) 
emergency transport HCPCS code if an emergency response and modifier QL for ground vehicles. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims 
Processing Manual, Chapter 15, Section 30.2. 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. 
  
   Therapy services are considered reasonable and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and  
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
The local Medicare Administrative Contractor has published its interpretation of the various outpatient therapy 
rules which provide more specific criteria for certain services. You can find this information in the Local 
Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631). 
 
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 physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. You can find this information in the Centers 
for Medicare and Medicaid Service, Internet-Only Manual, Publication Number 100-04, Medicare Claims 
Processing Manual, Chapter 12, Section 30.6.5. 
 
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, in terms of outpatient rehabilitation therapy services, a qualified professional means a 
physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical 
nurse specialist, or physicians assistant, who is licensed or certified by the state to furnish therapy services, 
and who also may appropriately furnish therapy services under Medicare policies. Qualified professional may 
also include a physical therapist assistant (PTA) or an occupational therapy assistant (OTA) when furnishing 
services under the supervision of a qualified therapist, who is working within the state scope of practice in the 
state in which the services are furnished. Assistants are limited in the services they may furnish and may not 
supervise other therapy caregivers. You can find this information in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Section 220. 
 
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. 
 
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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
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 12 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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 104 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 state that treatment for LUTS/BPH treatment will be considered medically reasonable and necessary 
when performed ONCE in patients with the following: 
 
Indications including ALL of the following: 
Age =80 
Prostate volume of 30-150 cc by transrectal ultrasound (TRUS)4,5 
Persistent moderate to severe symptoms despite maximal medical management 
including ALL of the following: 
 
International Prostate Symptom Score (IPSS) =124 
Maximum urinary flow rate (Qmax) of =15 mL/s4 (voided volume greater than 125 cc) 
Failure, contraindication or intolerance to at least three months of conventional medical therapy for LUTS/BPH 
(e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
Only treatment using an FDA approved/cleared device will be considered medically reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Transurethral Waterjet Ablation of 
the Prostate L38712. 
 
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 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). 
 
The rules say that Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography 
(CCTA) is not covered for screening, i.e., in the absence of signs, symptoms, or disease. These tests will be 
considered not medically necessary if the anticipated results are not expected to provide new, additional 
information to that already previously obtained from other tests (such as stress myocardial perfusion images or 
cardiac ultrasound). New or additional information should facilitate the management decision, not merely add a 
new layer of testing. You can find this rule in the Local Coverage Determination (LCD) - Cardiac Computed 
Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) (L33559). 
 
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.