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 Pharmacogenetics testing will be considered medically reasonable and necessary if: 
1. The patient has a condition where clinical evaluation has determined the need for a medication that has 
a known gene-drug interaction(s) for which the test results would directly impact the drug management 
of the patients condition; AND 
2. The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-
reviewed process and determined to demonstrate actionability in clinical decision making by CPIC 
guideline level A or B
1
; or is listed in the FDA table of known gene-drug interactions where data 
support therapeutic recommendations or a potential impact on safety or response or the FDA label; 
https://www.fda.gov/drugs/science-and-research-drugs/table-pharmacogenomic-biomarkers-drug-
labeling ; https://www.fda.gov/medical-devices/precision-medicine/table-pharmacogenetic-associations  
You can find this rule in Local Coverage Determination (LCD) Pharmacogenomics Testing L39073. 
 
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 test panel is a single test with multiple components and is characterized by a single unit 
of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact 
that the test reports multiple individual pathogens and/or targets.  
You can find this rule in the Local Coverage Article Billing and Coding: MolDX: Molecular Syndromic Panels 
for Infectious Disease Pathogen Identification Testing, A58747. 
 
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 Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate 
payment for multiple methods to test for the same analyte. You can find this rule in Local Coverage Article 
Billing and Coding: 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 state that effective for claims with dates of service July 1, 2007, and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only 
Manual, Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
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 a harness (E2313) describes all the wires, fuse boxes, fuses, circuits, switches, etc. that are
required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors,
and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial
issue and with complete replacement of the expandable controller. Code K0108 must not be used for any
component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of
complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if
individual components of the harness are replaced, code K0108 should be used. Procedure codes E2310 and
E2311 describe the electronic components that allow the beneficiary to control two or more of the following
motors from a single interface (e.g., proportional joystick, touchpad, or nonproportional interface): power
wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation,
power standing. It includes a function selection switch which allows the beneficiary to select the motor that is
being controlled and an indicator feature to visually show which function has been selected. When the
wheelchair drive function has been selected, the indicator feature may also show the direction that has been
selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be
integrated into the wheelchair interface. Payment for the code includes an allowance for fixed mounting
hardware for the control box and for the display box (if present). You can find this information in Local
Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

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 a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan is considered 
reasonable and necessary in enrollees with a recent diagnosis of dementia and documented cognitive decline of 
  
  at least 6 months, who meet diagnostic criteria for both Alzheimer's disease (AD) and frontotemporal dementia 
(FTD). These enrollees have been evaluated for specific alternate neurodegenerative diseases or other causative 
factors, but the cause of the clinical symptoms remains uncertain. You can find these rules in National 
Coverage Determination (NCD) FDG PET for Dementia and Neurodegenerative Diseases (220.6.13).  
 
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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
 The rules say that Providers/suppliers shall report the HCPCS/CPT code that describes the procedure 
performed to the greatest specificity possible. A Healthcare Common Procedure Coding System/Current 
Procedural Terminology (HCPCS/CPT) code shall be reported only if all services described by the code are 
performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 2023 National 
Correct Coding Initiative (NCCI) Policy Manual, Chapter X, Page 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 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 a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, 
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is 
covered for beneficiaries whose functional level is 3 or above. 
 
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, 
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY 
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below: 
1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee. 
2. K3 functional level only. 
3. Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or 
quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee 
alone. 
4. Is able to make use of a product that requires daily charging. 
5. Is able to understand and respond to error alerts and alarms indicating problems with the function of the 
unit. If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. you can find this in Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. The Plan has a Point-of-Service (POS) option to cover out-of-
services. Prior authorization rules apply. You can find this information on page(s) 42 of the Plan's 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 definitive urine drug testing (UDT) is considered reasonable and necessary when the clinical 
information supplied supports the definitive testing as in: 
 
1. Identifies a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
2. Definitively identifies specific drugs in a large family of drugs; 
3. Identifies a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. Identifies drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
5. Identifies a negative or confirms a positive presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
6. Rules out an error as the cause of a presumptive UDT result; 
7. Identifies non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
8. For use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
You can find this rule in the Local Coverage Determination (LCD) - Urine Drug Testing (L35724). 
 
The rules say that definitive UDT may be reasonable and necessary based on patient specific indications, 
including historical use, medication response, and clinical assessment, when accurate results are necessary to 
make clinical decisions. To establish that a test is reasonable and necessary, the clinicians rationale for the 
definitive UDT and the tests ordered must be documented in the patients medical record. You can find this 
rule in the Local Coverage Determination (LCD) - Urine Drug Testing (L35724). 
 
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 an OPPS payment status indicator is assigned to every HCPCS code. The status indicator 
identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment 
is made separately or packaged. You can find this rule in the Centers for Medicare & Medicaid Services (CMS) 
Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.1.1. 
 
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 state 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 
Alzheimer's 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. This rule is 
found in National Coverage Determination (NCD): Monoclonal Antibodies Directed Against Amyloid for the 
Treatment of Alzheimer's Disease (AD) 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 the home health agency (HHA) reports the date of the first visit provided in the admission as 
the "From" date. The "Through" date on the notice of admission (NOA) must always match the "From" date. 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2. 
 
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 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 rule say that genes not identified as having actionable use are not considered reasonable and necessary. 
The algorithms employed in combinatorial testing are also not currently considered reasonable and necessary 
components of multi-gene testing. You can find this rule in Local Coverage Determination (LCD) MolDX: 
Pharmacogenomics Testing L38394. 
 
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 pays for services only when they are furnished by a provider or supplier enrolled in 
the Medicare program. You can find this rule in the Centers for Medicare & Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-08, Program Integrity Manual, Chapter 15, Section 15.1. 
 
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 plans must make services geographically accessible and consistent with local community 
patterns of care. Commonly used services should be available within a reasonable distance and travel time. 
Longer distances and travel times are permissible when they are based on location (such as a rural area) and/or 
established and based on routine patterns of care. 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 110.1. 
 
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. 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 6 of the Plan's 2023 
Evidence of Coverage (EOC).