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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that a panel of genes is a distinct procedural service from a series of individual genes. All 
services billed to Medicare must be medically reasonable and necessary. As such, if a provider or supplier 
submits a claim for a panel, then the patients medical record must reflect that the panel was medically 
reasonable and necessary. Alternatively, if a provider or supplier bills for individual genes, then the patients 
medical record must reflect that each individual gene is medically reasonable and necessary. If the laboratory 
method is NGS testing, and the laboratory assays two (2) or more genes in a patient in parallel, then those two 
(2) or more genes will be considered part of the same panel, consistent with the NCCI manual Chapter 10, 
Section F, number 8. You can find this rule in the Local Coverage Article for the Billing and Coding of 
Molecular Pathology and Genetic Testing, A58917. 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 13 of the Plan's 2023 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that this is a non-coverage policy for genetic testing for the MTHFR gene which encodes the 
5,10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for all risk factors, signs, 
symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for 
pregnant patients. You can find this rule in the Local Coverage Determination (LCD) for MolDX: Genetic 
Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR), 
L35984. 
 
The rules state that PGx testing is not covered when a treating clinician is not considering treatment with a 
medication that has an actionable drug-gene interaction, or when the use of a medication with a drug-gene 
interaction is not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) 
for MolDX: Pharmacogenomics Testing, L38394. 
 
The rules also say that GeneSight Psychotripic testing is not covered. You can find this information at 
https://app.dexzcodes.com/app#!catalogDetailPage. 
 
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). 
 
The rules say that a GIP test panel is a single service with a single unit of service (UOS=1). A GIP test panel 
must not be unbundled and billed as individual components regardless of the fact that the GIP test panel reports 
multiple individual pathogens and/or targets. You can find this rule in the Local Coverage Article for 
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs), 
A56642. 
 
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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
The rules say that certain individuals and entities are not eligible to enroll in Medicare. If the contractor 
receives an enrollment application from any of these individuals or entities, the contractor shall deny the 
application. Marriage Family Therapists are listed as one of the provider types that is not eligible to enroll in 
Medicare. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 1, 10.2.8.  
 
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 the Centers for Medicare & Medicaid Services (CMS) covers percutaneous left atrial 
appendage closure (LAAC) for non-valvular atrial fibrillation (NVAF) through Coverage with Evidence 
Development (CED) with the following conditions: 
a. LAAC devices are covered when the device has received Food and Drug Administration (FDA) 
Premarket Approval (PMA) for that devices FDA-approved indication and meet all of the conditions 
specified below. The patient must have: 
- A CHADS2 score of 2 or more (Congestive heart failure, Hypertension, Age greater than 75, 
Diabetes, Stroke/transient ischemia attack/thromboembolism) or CHA2DS2-VASc score of 3 or 
more (Congestive heart failure, Hypertension, Age 65 or greater, Diabetes, Stroke/transient 
ischemia attack/thromboembolism, Vascular disease, Sex category) 
- A formal shared decision-making interaction with an independent non-interventional physician 
using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to 
LAAC. Additionally, the shared decision-making interaction must be documented in the medical 
record. 
- A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation 
following the conclusion of shared decision making, as LAAC is only covered as a second line 
therapy to oral anticoagulants. The patient (preoperatively and postoperatively) is under the care 
of a cohesive, multidisciplinary team (MDT) of medical professionals. The procedure must be 
furnished in a hospital with an established structural heart disease (SHD) and/or 
electrophysiology (EP) program. 
 
You can find these rules in National Coverage Determination (NCD) Percutaneous Left Atrial Appendage 
Closure (LAAC) (20.34). 
 
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 effective April 7, 2022, the Centers for Medicare & Medicaid Services (CMS) covers Food 
and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for the treatment of 
Alzheimers disease (AD) when furnished in accordance with Section B under coverage with evidence 
development (CED) for patients who have a clinical diagnosis of mild cognitive impairment (MCI) due to AD 
or mild AD dementia, both with confirmed presence of amyloid beta pathology consistent with AD. You can 
find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 200.3. 
 
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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aids are covered by the Plan every 3 years, up to a maximum of $500. The Plan 
contract says that services which are not considered medically reasonable and necessary are not covered. You 
can find this information on page 69 and 105 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 say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
 
    1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
    2. 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 of the beneficiarys seating and positioning needs. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and 
    3. 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. 
    4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
    5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to 
independently transfer from the wheelchair to bed; or 
    6. The power seating system is needed to manage increased tone or spasticity. 
 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.  
 
You can find this information in the Local Coverage Determination (LCD) for 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 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 state that payment may be made under the physician fee schedule for the professional component of 
physician laboratory or physician pathology services furnished to hospital inpatients or outpatients. Payment is 
not made under the physician fee schedule for technical component (TC) services furnished in institutional 
settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient 
settings. For services furnished on or after July 1, 2012, an independent laboratory may not bill the Medicare 
contractor (and the Medicare contractor may not pay) for the TC of a physician pathology service furnished to 
a hospital inpatient or outpatient. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 
60. 
 
The rules also state that laboratory tests performed for a skilled nursing facility's (SNF) Medicare inpatients 
covered under Part A are included in the prospective payment system (PPS) SNF payment. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 7, Section 90. 
 
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 service, but needs prior authorization. You can find this information on pages 75-78 and 81-85 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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c).  
 Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when they 
are medically necessary for the individual beneficiary and the medical necessity is documented by the treating 
practitioner. Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for 
beneficiaries with functional vision in only one eye. In this situation, an impact-resistant material is covered for 
both lenses, if eyeglasses are covered. Claims for code V2784 that do not meet this coverage criterion will be 
denied as not reasonable and necessary. You can find this information in the Local Coverage Determination 
LCD-Refractive Lenses (L33793). 
 
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-covered services-therefore not reasonable and necessary services include: 
1. Blanket Orders-same orders for all patients in a health care providers practice. 
2. Reflex definitive UDT is not reasonable and necessary when presumptive testing is performed at point 
of care because the clinician may have sufficient information to manage the patient. If the clinician is 
not satisfied, he/she must determine the clinical appropriateness of and order specific subsequent 
definitive testing (e.g., the patient admits to using a particular drug, or the IA cut-off is set at such a 
point that is sufficiently low that the physician is satisfied with the presumptive test result). 
3. Routine standing orders for all patients in a physicians practice are not reasonable and necessary. 
You can find the rules in Local Coverage Determination (LCD) Urine 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. 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 33 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 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 43 to 44 of the Plan's 
2023 Evidence of Coverage (EOC).