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

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that criteria to establish medical necessity for drug testing must be based on patient-specific 
elements identified during the clinical assessment, and documented by the clinician in the patients medical 
record and minimally include the following elements: 
 
Patient history, physical examination and previous laboratory findings 
Current treatment plan 
Prescribed medication(s) 
Risk assessment plan 
National pain organizations, physician societies, and the Federation of State Medical Boards recommend a 
practical approach to definitive UDT for COT. Frequency of testing beyond the baseline presumptive UDT 
screen must be based on individual patient needs substantiated by documentation in the patients medical 
record.  
 
Depending on the patients specific substance use history, definitive UDT to accurately determine the specific 
drugs in the patients system may be necessary. Definitive testing may be ordered when accurate and reliable 
results are necessary to integrate treatment decisions and clinical assessment. The frequency and the rationale 
for definitive UDT must be documented in the patients medical record. 
 
a.  For patients with 0 to 30 consecutive days of abstinence, definitive UDT is expected at a frequency not to 
exceed 1 physician-directed testing profile in one week. More than 1 physician-directed testing profile in one 
week is not reasonable and necessary and is not covered by Medicare 
 
b. For patients with 31 to 90 consecutive days of abstinence, definitive UDT is expected at a frequency 1  
physician-directed testing profiles in one month. More than 3 UDT in one month is not reasonable and 
necessary and is not covered by Medicare 
 
c.  For patients with >90 consecutive days of abstinence, definitive UDT is expected at a frequency 1  3 
physician-directed testing profiles in one month. More than 3 UDT in three months is not reasonable and 
necessary and is not covered by Medicare.  
You can find this information in the Local Coverage Determination (LCD) Controlled Substance Monitoring 
and Drugs of Abuse Testing L36393. 
 
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 state that the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or 
microphlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous 
reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy.   
 
The components of the conservative therapy include, but are not limited to: 
 
weight reduction, 
a daily exercise plan, 
periodic leg elevation, and 
the use of graduated compression stockings. 
The conservative therapy must be documented in the medical record. Inability to tolerate compressive bandages 
or stockings and the reason for such intolerance must be documented in the medical record. 
 
The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased 
vessels of the lower extremities are documented in the medical record: 
 
stasis ulcer of the lower leg, 
significant pain and significant edema that interferes with activities of daily living, 
bleeding associated with the diseased vessels of the lower extremities, 
recurrent episodes of superficial phlebitis, 
stasis dermatitis, or 
refractory dependent edema. 
Coverage of endovenous ablation therapy is limited to patients with:  
 
a maximum vein diameter of 12 mm for CAE, PEM and MOCA; and 
absence of thrombosis or vein tortuosity, which would impair catheter advancement (except for PEM). 
Medicare includes payment for the ultrasound guidance in the payment for endovenous ablation procedures. 
 You can find this information in the Local Coverage Determination (LCD) Varicose Veins of the Lower 
Extremity, Treatment of L33575. 
 
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 state that proton beam therapy (PBT) is considered reasonable in instances where sparing the 
surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added 
clinical benefit to the patient. Examples of such an advantage might be: 
1. The target volume is in close proximity to one or more critical structures and a steep dose gradient 
outside the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s). 
2. A decrease in the amount of dose inhomogeneity in a large treatment volume is required to avoid an 
excessive dose "hotspot" within the treated volume to lessen the risk of excessive early or late normal 
tissue toxicity. 
3. A photon-based technique would increase the probability of clinically meaningful normal tissue toxicity 
by exceeding an integral dose-based metric associated with toxicity. 
4. The same or an immediately adjacent area has been previously irradiated, and the dose distribution 
within the patient must be sculpted to avoid exceeding the cumulative tolerance dose of nearby normal 
tissue. 
 
PBT may offer dosimetric advantages as well as added complexity over conventional radiotherapy, 3D 
Conformal Radiation Therapy (3-D CRT) or Intensity Modulated Radiation Therapy (IMRT). Before applying 
PBT techniques, a comprehensive understanding of the benefits and consequences is required. In addition to 
satisfying at least one of the four selection criteria noted above, the radiation oncologist's decision to employ 
PBT requires an informed assessment of the benefits and risks including: 
- Determination of patient suitability for PBT allowing for reproducible treatment delivery 
- Adequate definition of the target volumes and organs at risk (OARs) 
- Equipment capability, including ability to account for organ motion when relevant 
- Physician, physicist and staff training 
- Adequate quality assurance procedures. 
 
It is important to note that normal tissue dose volume histograms (DVHs) must be demonstrably improved with 
a PBT plan to validate coverage. Therefore, coverage decisions must extend beyond diagnosis codes to 
incorporate additional considerations of clinical scenario and medical necessity with appropriate 
documentation. The final determination of the appropriateness and medical necessity for PBT resides with the 
treating radiation oncologist who should document the justification for PBT for each patient. You can find 
these rules in Local Coverage Determination (LCD) Proton Beam Therapy L35075. 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 expanded panel testing is only indicated when targeted panel testing is not appropriate (i.e., 
will not provide sufficient information for the appropriate clinical management of the patient). Services that do 
not have Food and Drug Administration (FDA)-cleared/approved indicated uses, as well as FDA-approved 
tests performed in ways not consistent with their intended-use labeling directions, will require registration with 
Molecular Diagnostic Services Program (MolDX) and a Technical Assessment (TA) to demonstrate 
compliance of the service with this policy. Similarly, tests for which there are no accompanying ICD-10 codes 
in the associated Billing and Coding Article will require registration with MolDX and a TA to demonstrate 
compliance of the service with this policy. 
 
    -Registered tests must demonstrate equivalent or superior test performance characteristics - analytical 
validity (AV) and clinical validity (CV) - to established standard-of-care (SOC) methods (i.e., culture, 
pathogen-specific polymerase chain reaction for the majority of targets included on the panel. 
    -CV of any new organisms and analytes that are not already established as SOC or that do not have a 
predicate test that is covered by this contractor, must be established through a study published in the peer-
reviewed literature for the intended use of the test in the intended population. 
 
Documentation of the following is clearly stated in the medical record: 
 
    -Specific clinical indications for testing (i.e. Clinical suspicion of a pathogen as the cause of the patients 
condition. 
    -Specific reasons for performing panel testing 
    -Provider type/specialty and Place of Service 
 
You can find this information in Local Coverage Determination (LCD): MolDX: Molecular Syndromic Panels 
for Infection 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 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 partial denture (D6113) up to a $200 allowance. You can find this information on page A1-11 of the 
Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays for care in a SNF when all of the following four factors are met: 
 
1. The patient requires skilled nursing or skilled rehabilitation services; 
  
  2. The patient requires these services on a daily basis; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patients illness or injury or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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 68-69 of the Plans 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 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 64-65 of the Plans 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 a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).  
 
  
  The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 Group 3 power wheelchair (PWC) with Multiple Power Options (K0861) is covered if the 
beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; 
and either the beneficiary meets coverage criteria for a power tilt and recline seating system and the system is 
being used on the wheelchair or the beneficiary uses a ventilator which is mounted on the wheelchair. 
 
If the PWC base is not covered, then related accessories will be denied. 
 
You can find this rule in Local Coverage Determination (LCD):Power Mobility Devices (L33789). 
 
A power seating system  tilt only, recline only, or combination tilt and recline  with or without power 
elevating legrests will be covered if 
 
    1. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
 
    2. The beneficiary utilizes intermittent catheterization for bladder management and is unable to 
independently transfer from the wheelchair to bed; or 
 
    3. The power seating system is needed to manage increased tone or spasticity. 
 
You can find this rule in Local Coverage Determination (LCD):Wheelchair Options/Accessories (L33792). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to two exams per year.You can find this information on pages 57-60 of 
the Plan's 2023 Evidence of Coverage (EOC).