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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) (L35025) and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) (A56853). 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. Physician Fee Schedule Status Indicator T means 
that there are relative value units and payment amounts for these services, but they are only paid if there are no 
other services payable under the physician fee schedule billed on the same date by the same provider.  If any other services are payable under the physician fee schedule and are billed by the same date by the same 
provider, these services are bundled into the physician services for which payment is made. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
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 a custom fabricated orthosis is covered when there is a documented physical characteristic 
which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of 
situations which meet the criterion for a custom fabricated orthosis include, but are not limited to: 
 
    Deformity of the leg or knee; 
 
    Size of thigh and calf; 
 
    Minimal muscle mass upon which to suspend an orthosis. 
 
Although these are examples of potential situations where a custom fabricated orthosis may be appropriate, 
suppliers must consider prefabricated alternatives such as pediatric knee orthoses in beneficiaries with small 
limbs, straps with additional length for large limbs, etc. 
 
If a custom fabricated orthosis is provided but the medical record does not document why that item is 
medically necessary instead of a prefabricated orthosis, the custom fabricated orthosis will be denied as not 
reasonable and necessary. 
 
Custom fabricated orthoses (L1834, L1840, L1844, L1846, L1860) are not reasonable and necessary in the 
treatment of knee contractures in cases where the beneficiary is nonambulatory. 
 
A custom fabricated knee orthosis with an adjustable flexion and extension joint (L1844, L1846) is covered if 
criteria 1 and 2 are met: 
 
    The coverage criteria for the prefabricated orthosis codes L1843, L1845, L1851 and L1852 are met; and 
 
    The general criterion defined above for a custom fabricated orthosis is met. 
 
 If an L1844 or L1846 orthosis is provided and both criteria 1 and 2 are not met the orthosis will be denied as 
not reasonable and necessary. 
 
A custom fabricated knee orthosis with a modified supracondylar prosthetic socket (L1860) is covered for a 
beneficiary who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee. 
You can find this information in the Local Coverage Determination (LCD) Knee Orthoses L33318. 
 
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of 
the specific patient involved. 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 220.2(B). 
 
The rules say that cardiac computed tomographic angiography (CCTA) can be used for evaluation of chest pain 
syndrome when there is: 
 
-Intermediate pre-test probability of CAD and 
-Uninterpretable EKG or patient is unable to exercise or 
-Uninterpretable or equivocal stress test (exercise, perfusion or stress echocardiogram (echo). 
 
You can find this rule in the Local Coverage Determination (LCD)  Cardiac Computed Tomographic 
Angiography (CCTA) (L33423). 
 
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 non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. You can find this 
information in Local Coverage Determination (LCD) Biomarkers for Oncology L35396. 
 
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 43 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 state that molecular syndromic infectious disease pathogen identification panel tests are covered for: 
 
1. Immunocompetent patients, when the clinical indication includes a presumption of active infection OR 
infection-associated complications (which may include exacerbation of underlying disease) that require the 
identification of a causative organism for appropriate management. Atypical clinical presentations of disease 
are considered appropriate indications for special populations who may not present with classic symptoms of 
infection (i.e., the elderly). 
2. Immunocompromised patients (i.e., those with weakened immune systems including those with human 
immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), patients who are taking 
immunosuppressive medications (i.e., chemotherapy, biologics, transplant-related immunosuppressive drugs, 
high-dose systemic corticosteroids) and those with inherited diseases that affect the immune system (i.e., 
congenital immunoglobulin deficiencies), atypical clinical presentations of disease are considered appropriate 
indications for testing. In this patient population, testing may be performed ONCE as part of a pre-transplant 
evaluation, regardless of the presence of symptoms. 
3. Patients where the results of testing will impact clinical management in a manner already demonstrated in 
the peer-reviewed published literature to improve patient outcomes. 
 
This information is found in Local Coverage Determination (LCD): MolDX: Molecular Syndromic Panels for 
Infectious Disease Pathogen Identification Testing (L38988). 
 
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The rules define a chronically ill enrollee as one who has one or more 
comorbid and medically complex chronic conditions that meet all of the following: 
1. Is life threatening or significantly limits the overall health or function of the enrollee; 
2. Has a high risk of hospitalization or other adverse health outcomes; and  
3. Requires intensive care coordination. 
The rules also say that the Plan must have written policies for determining enrollee eligibility and must 
document its determination that an enrollee is a chronically ill enrollee. You can find this information in 42 
CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 103-
105 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 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 tests have met the coverage criteria of the policy: Progensa PCA3 and 
ConfirmMDx. You can find this rule in Local Coverage Article Billing and Coding Billing and Coding: 
MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer A58718. 
 
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 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 pages 60-61 in 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 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). 
 
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 there is a $500 deductible which applies to certain items and services. The Plan 
deductible applies to the ophthalmological services, medical examination and an eye refraction. You can find 
this information on pages 4-2 to 4-4 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 state that effective for dates of service on or after July 1, 2011, all claim lines submitted with the GZ 
modifier will be automatically denied. You can find this rule at Centers for Medicare and Medicaid Services, 
Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 23, Section 20.9.1.1. 
 
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 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). 
 
When surgical dressings are billed, the appropriate modifier (A1  A9, AW, EY, or GY) must be added to the 
code when applicable. Claims lines for A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, 
A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, 
A6213, A6214, A6215, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, 
A6230, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, 
A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, 
A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6441, A6442, A6443, A6444, A6445, 
A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457 billed without 
A1-A9 modifiers will be rejected as missing information. You can find this rule in the Local Coverage Article 
(LCA): 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 say that coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator 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. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for 
beneficiaries whose functional level is 3 or above. You can find this rule in Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that an axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose 
functional level is 2 or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb 
Prostheses (L33787) - Effective January 1, 2020. 
 
 
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. 
 
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 supplemental coverage is provided for a flex allowance benefit. This benefit states 
that routine chiropractic services are covered up to the maximum of your flex allowance. You may receive the 
following covered routine chiropractic services at any time: chiropractic diagnostic and therapeutic services to 
manage the musculoskeletal conditions, subluxation coverage for chiropractic treated conditions including 
musculoskeletal conditions of the spine and extremities. You have up to $500 every year to spend on routine 
acupuncture, chiropractic, vision services, dental services, and hearing services. You will receive up to $250 
every six months. This amount will accumulate every six months. You can find this information on pages 52 
and 58 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 state that it has not been established that a moist electric heating pad (E0215) or water circulating 
heat pad with pump (E0217) is reasonable and necessary compared to a standard electric heating pad (E0210); 
therefore, if code E0215 or E0217 is provided it will be denied as not reasonable and necessary. You can find 
this information in Local Coverage Determination (LCD): Heating Pads and Lamps (L33784). 
 
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.