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 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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
 Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
 Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
 Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed 
test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of 
analytical validity and clinical utility; AND 
 Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
 For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases 
where a tiered approach/method is clinically available, testing would be covered ONLY for the number 
of genes or test that are reasonable and necessary to obtain necessary information for therapeutic 
decision making; AND 
 Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic 
genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical 
scenarios whereby repeat testing of somatically-acquired mutations (for example, pre- and post- 
therapy) may be required to inform appropriate therapeutic decision-making. 
You can find this rule in Local Coverage Determination (LCD) Molecular Pathology Procedures L35000. 
 
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 the date of service (DOS) for laboratory tests generally must be the date the specimen was 
collected; however, an exception is made for molecular pathology tests performed by a laboratory other than a 
blood bank. This requires that the DOS be reported as the date the testing was performed when: the test was 
performed following a hospital outpatient's discharge from the hospital outpatient department; the specimen 
was collected from a hospital outpatient during an encounter; and, it was medically appropriate to have 
collected the sample from the hospital outpatient during the hospital outpatient encounter. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 16, Section 40.8. 
 
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 Group 2 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 rule 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. 
 
The rules state that for hospital based services (inpatient/outpatient), it is expected that there should be an order 
for the 3D image. In the absence of the order for the 3D image, if the hospitals interpreting physician deems 
that the 3D interpretation is needed, he or she should clearly state in the interpretation the medical necessity for 
this separate service, in addition to the base procedure. You can find this rule in the Local Coverage 
Determination (LCD) for 3D Interpretation and Reporting of Imaging Studies (L33256). 
 
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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (median branch) nerves are considered medically reasonable and necessary for patients who meet ALL 
the following criteria: 
1.  
a.  Initial thermal RFA:  
i.  After the patient has had at least two (2) medically reasonable and necessary diagnostic 
medical branch blocks (MBBs), with each one providing a consistent minimum of 80% 
sustained relief of primary (index) pain (with the duration of relief being consistent with 
the agent used) AND 
ii. 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 information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38765). 
 
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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. 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 290(3). 
 
The rules say that with the exception of the situations described above, orthopedic footwear billed using code 
L3020 will be denied as non-covered.  
 
You can find this information at Local Coverage Article: Orthopedic Footwear-Policy Article (A52481). 
 
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 test panel is a single test with multiple components and is characterized by a single unit of 
service. A panel cannot be unbundled and billed as individual components regardless of the fact that the test 
reports multiple individual pathogens and/or targets. If additional organisms are not included in a panel, testing 
for those organisms separately may be reasonable and necessary when ordered in addition to the panel and 
supported by documentation in the medical record. You can find this rule in the Local Coverage Article (LCA) 
for Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification 
Testing (A58710). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 says that manual manipulation of the spine to correct a subluxation is covered. Additionally, 
the Plan contract says that supplemental (extra) coverage is provided for spine x-rays and chiropractic 
radiology services. You can find this information on page 55 of the Plans 2022 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 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 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 DEX Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. You can find this rule in the Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L35160). 
 
To report a Molecular Diagnostic Test service, please submit the following claim information: 
 Select appropriate CPT code 
 Enter 1 unit of service (UOS) 
 Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the 
following Part B claim field/types: 
o Loop 2400 or SV101-7 for the 5010A1 837P 
o Box 19 for paper claim 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage Article 
(LCA) - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A57526). 
 
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 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 DEX Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. You can find this rule in the Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L35160). 
 
To report a Pigmented Lesion Assay service, please submit the following claim information: 
 Select appropriate CPT code 
 Enter 1 unit of service (UOS) 
 Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the 
following Part B claim field/types: 
o Loop 2400 or SV101-7 for the 5010A1 837P 
o Box 19 for paper claim 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage Article 
(LCA) - Billing and Coding: MolDX: Pigmented Lesion Assay (A58052). 
 
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 the following is a list of suppliers who frequently attempt to enroll in Medicare but are not 
eligible to do so; no statute permits them to bill Medicare. Note that this list is not exhaustive. If the contractor 
receives an enrollment application with one of the following types listed thereon, the contractor shall deny the 
application without development.  
     Substance Abuse Facility 
You can find this rule in the Medicare Program Integrity Manual Chapter 10 - Medicare Provider/Supplier 
Enrollment-6.2.1 - Suppliers Not Eligible to Participate. 
 
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 Medicare will consider invasive procedures (only with the techniques outlined in this local 
coverage determination (LCD) and under the conditions described) as reasonable and necessary when 
documentation in the medical record includes a history, physical examination, CEAP clinical classification, and 
a venous duplex scan documenting reflux (greater than 500 msec). 
 
    Liquid sclerotherapy will be considered reasonable and necessary to treat telangiectasias, reticular veins, 
small varicose veins (3-6 mm), residual or recurrent veins following endovenous ablation or surgery, and 
perforator veins. Treatment of telangiectasias and reticular veins (C1) (less than 3 mm) is considered 
reasonable and necessary with documentation of spontaneous and/or traumatic venous hemorrhage, OR for 
dilated intradermal veins in the elderly judged to be a substantial risk for hemorrhage with minimal trauma, OR 
near an active or healed ulcer if judged to contribute to local venous hypertension. 
    Saphenous veins (GSV, SSV, AAGSV) management, with UGFS, endovenous thermal ablation 
(radiofrequency or laser), chemical adhesive (cyanoacrylate embolization), MOCA, and surgery (surgical 
ligation and stripping) is considered reasonable and necessary with documentation in the medical record of 
CEAP class C2-C6 disease, reflux (>500 msec), and ANY of the following signs or symptoms: 
        ulceration secondary to venous stasis; 
        significant pain or significant edema associated with saphenous reflux that interferes with activities of 
daily living (ADLs); 
        bleeding associated with ruptured superficial varicosity; 
        recurrent episodes of superficial phlebitis; 
        stasis dermatitis; 
        refractory dependent edema 
    Incompetent perforator veins (IPVs) are the most common cause of recurrent varicose veins after treatment. 
Minimally invasive treatments have replaced traditional surgical treatments for IPVs. UGFS and endovenous 
thermal ablation with either radiofrequency or laser energy sources will be considered reasonable and 
necessary9 with the following conditions: 
        Demonstrated perforator reflux greater than 500 msec; AND 
        No saphenous reflux (greater, small, or accessory) and/or symptomatic varicose tributaries; AND 
        An active venous ulcer; AND         The IPV is at least 3.5 mm in diameter; AND 
        The perforator is in the vicinity of the ulcer. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Treatment of Varicose 
Veins of the Lower Extremities (L39121). 
 
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say that a Group 2 Single Power Option PWC (K0835, K0836, K0837, K0838, K0839, K0840) is 
covered if all of the coverage criteria (a)-(e) for a PWC are met and if:  
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met.  
1. The beneficiary requires a drive control interface other than a hand or chin-operated standard 
proportional joystick (examples include but are not limited to head control, sip and puff, switch 
control). 
2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system (see 
Wheelchair Options and Accessories policy for coverage criteria) and the system is being used 
on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical therapist (PT) or occupational therapist (OT), or 
practitioner who has specific training and experience in rehabilitation wheelchair evaluations 
and that documents the medical necessity for the wheelchair and its special features (see 
Documentation Requirements section). The PT, OT, or practitioner may have no financial 
relationship with the supplier. 4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology 
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in 
the wheelchair selection for the beneficiary. 
If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not met (including but not 
limited to situations in which it is only provided to accommodate a power seat elevation feature, a power 
standing feature, or power elevating legrests), it will be denied as not reasonable and necessary. You can find 
these rules 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 state that it has not been established that a water circulating heat pad with pump (E0217) is 
reasonable and necessary compared to a standard electric heating pad (E0210); therefore, if code E0217 is 
provided it will be denied as not reasonable and necessary. You can find this information in the Local Coverage 
Determination (LCD): Heating Pads and Heat 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.
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 41 and 44 of the Plan's 
2021 Evidence of Coverage (EOC).