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 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. 
 
The rules say that Ibandronate sodium, pamidronate or zoledronic acid are covered for treatment of 
osteoporosis when there are no drug classification contraindications. There also needs to exist either one or 
more of the following: 
 
  1. Demonstrated intolerance or contraindication for Food and Drug Administration (FDA) approved oral 
bisphosphonates dosing regimens, or insurmountable issues related to absorption, compliance or dosing 
posture. 
  2. When adequate trials of FDA-approved oral bisphosphonates result in fallen Bone Mass Density and/or 
failure to suppress bone turnover (e.g. persisting high bone -turnover marker measurements). 
 
Evidence in the medical record should clearly support the need for the intravenous administration of 
bisphosphonates for the treatment of osteoporosis. You can find this rule in the Local Coverage Determination 
(LCD): Bisphosphonate Drug Therapy (L34648). 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
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 enrollees must pay a 20% coinsurance for Medicare Part B drugs. You can find this 
information on pages 72 to 73 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that for upper lid blepharoplasty: 
 
1.Photographs of the affected eyelid(s) in both frontal (straight ahead) and lateral (from the side) 
positions demonstrate the physical signs in Section A. Oblique photos are only necessary if needed to 
better demonstrate a finding not clearly shown by frontal and lateral photos. 
 
You can find this information in the Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, 
and Brow Lift (L36286). 
 
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 genetic testing for known or suspected myeloid malignancies may be covered when certain 
criteria are met. For patients that do not have a diagnosis of a myeloid malignancy, where one is suspected, the 
  
  patient must have an undefined cytopenia for greater than 4 months, with other possible causes have been 
reasonably excluded.  
 
The testing must have also satisfactorily completed a technical assessment (TA) with the MolDX contractor. 
You can find this in the Local Coverage Determination (LCD): MolDX: Next-Generation Sequencing Lab-
Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (L38047). 
 
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 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 information in 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 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 case-mix methodology adjusts the 30-day payment rate based on characteristics of the 
patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other 
factors). The 30-day period payment rate is adjusted by a case-mix methodology based on information from 
home health claims, other Medicare claims, and data elements from the Outcome and Assessment Information 
Set (OASIS). The claims information and OASIS data elements are used to group 30-day periods of care into 
their case-mix groups. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
Benefit Policy Manual, Chapter 7, Section 10.2. 
 
The rules say that Home Health Resource Groups (HHRGs) and HIPPS Codes, Under the home health 
prospective payment system as refined by the Patient- Driven Groupings Model, a case-mix adjusted payment 
for a 30-day period of care is made using one of 432 HHRGs. On Medicare claims, these HHRGs are 
represented as Health Insurance Prospective Payment System (HIPPS) codes. HIPPS code rates represent 
specific characteristics (or case-mix) on which Medicare payment determinations are made. You can find this 
rule in the Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual Chapter 10, 
Section 10.1.8. 
 
The rules say that a case-mix methodology adjusts the 30-day payment rate based on characteristics of the 
patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other 
factors). The 30-day period payment rate is adjusted by a case-mix methodology based on information from 
home health claims, other Medicare claims, and data elements from the Outcome and Assessment Information Set (OASIS). The claims information and OASIS data elements are used to group 30-day periods of care into 
their case-mix groups. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare 
Benefit Policy Manual Chapter 7, Section 10.2. 
 
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 say that for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
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. The contract 
says that the Plan offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit 
covers routine acupuncture services (limited to 6 visits whether done in or out-of-network) for other conditions 
such as headaches, anxiety, sleep issues, osteoarthritis, chemotherapy side effects and respiratory disorders. 
You can find this information on page 69 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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A56853. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. 
 
The rules say that the Physician Fee Schedule Status Indicator T means that there are payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule 
billed on the same date by the same provider. If any other services payable under the physician fee schedule are 
billed on the same date by the same provider, these services are bundled into the physician services for which 
payment is made. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-
104, Chapter 4, Section 10.4. 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
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 enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page 83 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that Guardant360 is covered only when all of 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 a neurotrophic receptor tyrosine kinase (NTRK) mutation may be considered 
to have advanced cancer, and 
 Patient has not previously been tested with the Guardant360 test for the same genetic content. For a 
patient who has been tested previously using Guardant360 for cancer, that patient may not be tested 
again unless there is clinical evidence that the cancer has evolved wherein testing would be performed 
for different genetic content. Specifically, in patients with previously tested cancer, who have evidence 
of new malignant growth despite response to a prior targeted therapy, that growth may be considered to 
be sufficiently genetically different to require additional genetic testing, and 
 Patient is untreated for the 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:  o The patient is a candidate for further treatment with a drug that is either FDA-approved for that 
patients cancer, or has a National Comprehensive Cancer Network (NCCN) 1 or NCCN 2A 
recommendation for that patients cancer, and  
o 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, comprehensive genomic profiling (CGP) is infeasible (e.g., quantity not sufficient for 
tissue-based CGP or invasive biopsy is medically contraindicated) or specifically in NSLC Tissue-
based CGP has shown no actionable mutations. 
You can find this rule in Local Coverage Determination (LCD) MolDX: Plasma-Based Genomic Profiling in 
Solid Tumors L39230. 
 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that BCR/ABL is indicated in patients with suspected CML with either persistent, unexplained 
leukocytosis or thrombocytosis. BCR/ABL is considered medically necessary in the evaluation of individuals 
with chronic myelogenous leukemia or BCR-ABL positive acute lymphoblastic leukemia to evaluate treated 
individuals who manifest suboptimal response to initial tyrosine kinase inhibitor therapy or loss of response to 
tyrosine kinase inhibitor therapy. 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 the routine physical checkup exclusion applies to (a) examinations performed without 
relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. You can find this information in the Medicare Benefit Policy Manual, Chapter 16 - General 
Exclusions From Coverage, Section 90 - Routine Services and Appliances. 
 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that pharmacogenomics testing (PGx) testing is not considered reasonable and necessary merely 
on the basis of a patient having a particular diagnosis. Unless the record reflects that the treating clinician has 
already considered non-genetic factors to make a preliminary drug selection, PGx testing is not considered 
reasonable and necessary. You can find this rule in Local Coverage Determination (LCD) MolDX: 
Pharmacogenomics Testing L38294. 
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.