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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
  
  provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 160. 
 
The rules say that treatment for temporomandibular joint (TMJ) syndrome may be covered when the actual 
condition or symptom is medical in nature and the services provided are reasonable and necessary for the 
diagnosis and/or treatment of a medical illness or injury. 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 150.1. 
 
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 molecular pathology procedures (Tier1 and Tier2) may be eligible for coverage when ALL 
of the following criteria are met: 
 
1. Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
2. Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
3. 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 
4. Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
5. 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 
6. 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 the 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 definitive drug testing is indicated when: 
 
1. The results of the screen are presumptively positive. 
2, Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive 
test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids. 
 
You can find this rule in the Local Coverage Determination (LCD) - Drug Testing (L34645). 
 
The rules say that drugs, or drug classes for which testing is performed, should reflect only those likely to be 
present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in 
common use. Drugs for which specimens are being tested must be indicated by the referring provider in a 
written order. You can find this rule in the Local Coverage Determination (LCD) - Drug Testing (L34645). 
 
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 cardiovascular nuclear imaging is indicated for the following: 
 
1. Assessment of the functional and prognostic importance of angina; 
2. Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal electrocardiogram (ECG) 
changes caused by drugs, bundle branch block, or left ventricular hypertrophy; 
3. Assessment of congenital anomalies of coronary arteries; 
4. Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with 
known atherosclerotic heart disease on catheterization or single-photon emission computerized 
tomography (SPECT) perfusion imaging, who have not had a revascularization procedure within the past two 
years; 
5. Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed 
heart failure or left ventricular systolic dysfunction; 
6. Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary 
angiography are not planned; 
7. Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other 
re-perfusion procedures; 
8. Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; 
9. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or 
perioperative management in: 
 
a. patients with minor or intermediate clinical risk predictors and poor functional capacity; 
b. patients with intermediate or high likelihood of coronary heart disease, or 
c. patients with poor functional capacity undergoing high risk non-cardiac surgery; 
 
10. Evaluation of ventricular function in patients with non-ischemic myocardial disease; 
11. Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a 
determination of whether to implant a defibrillator or biventricular pacemaker; 
12. Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., 
adriamycin). 
 
You can find this rule in the Local Coverage Determination (LCD) - Cardiovascular Nuclear Medicine 
(L33560). 
 
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 Polyethylene-glycol (PEG) hydrogel is covered ONCE in patients with clinically localized 
prostate cancer with BOTH the following:  
1. Inclusion criteria including ALL of the following: 
a. Low* or Favorable Intermediate Prostate Cancer Risk Group (AUA or NCCN criteria) 
b. Dose escalated ( 76 Gy) conventional fractionation (1.8-2 Gy fractions) or moderate 
hypofractionation (HFX) (2.4-3.4 Gy fractions) IG-IMRT planned  
c. Eastern Cooperative Oncology Group (ECOG) performance status  1  
d. Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side 
effects due to AT LEAST ONE of the following: 
i. Anatomic geometry precluding ideal rectal constraints  
o Conventional fractionation (V70 <10%, V65 <20%, V40 <40%) 
o Moderate HPX (dose constraints not yet standardized; employ those used in the 
supporting phase III trials) 
ii. Medication usage (e.g., anticoagulants) 
iii. Comorbid conditions (e.g., increased age, Hx MI or CHF) 
2. No Exclusion criteria including ALL of the following: 
a. Less than 5-year life-expectancy and asymptomatic 
b. Prior prostate cancer treatment (surgery or RT) 
c. Active bleeding disorder or clinically significant coagulopathy 
d. Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, 
anorectal IBD) 
e. Prostate volume > 80 cc 
*Life expectancy  20 y (very low risk);  10 y (low risk) 
You can find this rule at the Medicare Local Coverage Determination (LCD) L37485: Prostate Rectal Spacers. 
 
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 Guardant360 remains covered for patients with non-central nervous system (CNS) 
originated solid tumors when the following conditions are met: 
  
   
- Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did 
not originate from the central nervous system. Patients who would meet all of the indications on the Food and 
Drug Administration (FDA) label for larotrectinib if they are found to have an NTRK mutation may be 
considered to have advanced cancer, and 
 
-Patient has not previously been tested with the Guardant360 test for the same primary cancer. For a patient 
who has been tested previously using Guardant360 for a cancer, that patient may only be tested again when 
the patient has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has 
evidence of new malignant growth, that growth may be considered to be a different primary cancer if it does 
not originate from the same cell line or it is physiologically different enough that it responds differently to 
treatment than the previously tested cancer, and 
 
- Patient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. 
progression or new lesions on treatment), and 
 
-The patient has decided to seek further cancer treatment with the following conditions: 
     -The patient is a candidate for further treatment with a drug that is either FDA-approved for that patients 
cancer, or has an National Comprehensive Cancer Network (NCCN) 1 or NCCN 2A recommendation for that 
patients cancer, and 
     -The FDA-approved indication or NCCN recommendation is based upon information about the presence or 
absence of a genetic biomarker tested for in the Guardant360 assay, and 
 
-Tissue-based testing is infeasible (i.e., quantity not sufficient for tissue-based testing or invasive biopsy is 
medically contraindicated) or specifically in non-small cell lung cancer (NSLC) Tissue-based testing has 
shown no actionable mutations. 
 
You can find this information in the Local Coverage Article (LCA): Billing and Coding: Guardant360 
(A58192). 
 
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 modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
The rules say that the physician must clearly document, in the medical record, his or her intent that the test be 
performed. An order is a communication from the treating physician/practitioner requesting that a diagnostic 
test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a 
particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by 
the treating physician/practitioner (e.g., if test X is negative, then perform test Y). You can find this rule in 
Medicare Benefit Policy Manual; Chapter 15, Section 80.6. 
 
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 does not include 
prefabricated post and cores. This benefit includes crowns but not if the damage is due to attrition, abrasion, 
erosion, or abfraction. You can find this information on page 51 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 the following indications are covered nationally unless otherwise indicated: 
1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed 
as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance 
at the time the service is performed or immediately thereafter. 
4. Home EKG services with documentation of medical necessity. 
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with 
respect to the physicians service in interpreting the results of such transmissions, including charges for 
rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is 
not considered DME separately. Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); 
(only if 24-hour coverage is provided). 
You can find this rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 20.15. 
 
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 sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-
frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation 
to determine if an implantable stimulator would be effective and a permanent implantation in appropriate 
candidates. Both the test and the permanent implantation are covered. 
 
The following limitations for coverage apply to all three indications: 
 
    Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical 
corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. 
    Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with 
peripheral nerve involvement) which are associated with secondary manifestations of the above three 
indications are excluded. 
    Patient must have had a successful test stimulation in order to support subsequent implantation. Before a 
patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through 
test stimulation. Improvement is measured through voiding diaries. 
    Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of 
the implant procedure can be properly evaluated. 
 
You can find this information in the National Coverage Determinations (NCD) Manual, Section 230.18. 
 
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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
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. 
 
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 page 3-4 of the Plans 2022 
Evidence of Coverage (EOC). 
 The Plan contract also says that the provider may need to obtain prior authorization and a referral is required 
for outpatient mental health care services. You can find this information on page 4-39 of the Plans 2022 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 local Medicare coverage of oncological biomarkers must be predicated upon four 
fundamental principles: 
 
1. First, the biomarkers must have proven clinical validity/utility (CVU).  
 
2. Second, to support the medical necessity of the service, there must be acceptance/uptake of specific testing 
into patient management. It is essential that physicians be familiar enough with all specific biomarkers, which 
they order, such that all test results may become clinically actionable. 
 
3. Providers managing oncological conditions must demonstrate that the use of biomarkers will be used to 
assist in the management/treatment of the beneficiary. 
 
4. Peer-reviewed full manuscript evidence is required to support combination panels for multiple biomarkers, 
particularly regarding their alleged composite clinical validity/utility. For example, such potential billing for 
multiple, diverse biomarkers (e.g., diagnostic/monitoring/prognostic/predictive) can only achieve medical 
necessity when it is clearly evident how each requested biomarker can be individually contributory. 
 
You can find this information in the 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.