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 modifiers were established to simplify billing for visits and other procedures which are 
furnished during the postoperative period of a surgical procedure, but which are not included in the payment 
for the surgical procedure. 
 
Modifier "-79": Reports an unrelated procedure by the same physician during a postoperative period. The 
physician may need to indicate that the performance of a procedure or service during a postoperative period 
was unrelated to the original procedure. 
 
A new postoperative period begins when the unrelated procedure is billed.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual Chapter 12, Section 
 
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 in order for opioid drugs for treatment of chronic intractable pain to be considered medically 
reasonable and necessary, all of the following criteria must be met: 
 
-The administration of the medication must require administration through the intrathecal route and be effective 
on a long-term basis. 
-The history of the patient's prior treatment should show oral or subcutaneous medication treatment was 
ineffective or complicated by unacceptable side effects. 
-The patient's medical condition must require the use of an infusion pump for pain relief. 
-The type and dosage of the medication must reasonably be expected to alleviate or reduce the pain. 
 
You can find this information in the Local Coverage Determination (LCD) L35112: Implantable Infusion 
Pump. 
 
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. 
Effective for services performed on or after April 4, 2005, cochlear implantation may be covered for treatment 
of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who 
demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of 
less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-set 
sentence cognition. Medicare coverage is provided only for those patients who meet all of the following 
selection guidelines. 
 Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids; 
 Cognitive ability to use auditory clues and a willingness to undergo an extended program of 
rehabilitation; 
 Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to 
implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous 
system; 
 No contraindications to surgery; and 
 The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations (NCD) Manual Chapter 1, Section 50.3. 
 
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 state that continuous passive motion devices are devices covered for patients who have received a 
total knee replacement. To qualify for coverage, use of the device must commence within 2 days following 
surgery. In addition, coverage is limited to that portion of the 3-week period following surgery during which 
the device is used in the patients home. There is insufficient evidence to justify coverage of these devices for 
longer periods of time or for other applications. You can find this rule in Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, National Coverage Determination (NCD): Durable 
Medical Equipment Reference List (280.1). 
 
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 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. 
 
Medicare Guidance says As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel 
by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, 
service providers should use 1-unit only of CPT code 81479 (used for the entire bundled multi-test panel) at 
this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the 
test; not unbundled to separate codes, or other unlisted code. You can find this Medicare guidance in the 
Medicare National Coverage Determination 90.2 Next Generation Sequencing, Medicare Local Coverage 
Article A58917 - Billing and Coding: Molecular Pathology and Genetic Testing, Code of Federal Regulation 
42 CFR 410, Subpart B - Medical and Other Health Services (screening tests), Medicare Claims Processing 
Manual Chapter 18 - Preventive and Screening Services. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that CPT code 61783 (Stereotactic computer-assisted (navigational) procedure; spinal...) shall 
not be reported for a simple spinal decompression (e.g., CPT codes 63001-63051). Stereotactic navigational 
procedures are usually performed to identify anatomy for precise treatments and avoid vital structures which 
are not necessary for a simple spinal decompression procedure. 
 
You can find this information in the Medicare NCCI 2022 Coding Policy Manual, Chapter 8. 
 
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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 8, and 30 of the Plan's 
2020 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 this LCD addresses use of water vapor thermal therapy for the treatment of lower urinary 
tract symptoms attributable to benign prostatic hyperplasia (LUTS/BPH).  
 
ONE treatment for LUTS/BPH treatment is covered ONCE in patients with BOTH the following:  
 
    1. Indications including ALL of the following: 
 
        a. Age greater than or equal to 50 
        b. Symptomatic despite maximal medical management including ALL of the following: 
 
            i. International Prostate Symptom Score (IPSS) greater than or equal to 13 
            ii. Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 
cc) 
            iii. Failure, contraindication or intolerance to at least three months of conventional medical therapy for 
BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
        c. Prostate volume of 30-80 cc, 
       d. Poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, 
pulmonary disease, etc.), or at high risk of bleeding 
 
    2. No contraindications including ALL of the following: 
 
        a. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines) or a 
prostate specific antigen (PSA) greater than 10 ng/mL 
        b. Active urinary tract infection 
        c. History of bacterial prostatitis in the past three months 
        d. Prior prostate surgery 
        e. Neurogenic bladder 
        f. Active urethral stricture (i.e., the source of the current LUTS) 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Water Vapor Thermal 
Therapy for LUTS/BPH (L37808). 
 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 DME MAC medical directors have reviewed information about the products billed using E0118 (crutch 
substitute). The determination is that there is insufficient published clinical literature demonstrating safety and 
effectiveness in the Medicare population to establish the medical necessity for these products. You can find this 
information in the Noridian Healthcare Solutions Medical Director Articles located at 
https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/e0118-crutch-substitute 
 
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 4% of the cost for Medicare-covered medical supply items. You can find 
this information page 20 of the Plan's 2020 Schedule of Cost Sharing.
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. 
 
Replacement refers to the provision of an identical or nearly identical item. Situations involving the provision 
of a different item because of a change in medical condition are not addressed in this section. 
 
Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable 
damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). A physician's 
order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical 
necessity of the item. 
 
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot 
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful 
lifetime of the equipment. If the item of equipment has been in continuous use by the patient on either a rental 
or purchase basis for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of 
equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is 
needed to reaffirm the medical necessity of the item. 
 
The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the 
absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of equipment, 
but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment is 
delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual Chapter 15, Section 110.2(C). 
 
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 continued coverage of a PAP device (E0470 or E0601) beyond the first three months of 
therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the 
treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from 
PAP therapy. 
 
For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is 
demonstrated by: 
 
    In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
SLEEP APNEA are improved; and, 
 
    Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
 
Adherence to therapy is defined as use of PAP =4 hours per night on 70% of nights during a consecutive thirty 
(30) day period anytime during the first three (3) months of initial usage. 
 
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as 
not reasonable and necessary. 
 
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 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 110.1.  
 
The rules say that the term durable medical equipment (DME) is defined as equipment which: 
 
    Can withstand repeated use; i.e., could normally be rented and used by successive patients; 
    Is primarily and customarily used to serve a medical purpose; 
    Generally is not useful to a person in the absence of illness or injury; and, 
    Is appropriate for use in a patients home 
 
Exercise Equipment; Deny - not primarily medical in nature (Section 1861(n) of the Act). You can find this 
information in Medicare's National Coverage Determination (NCD): Durable Medical Equipment Reference 
List (280.1). 
 
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 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). 
 
Code L5999 (LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED) must not be used to 
bill for any features or functions included in the socket or addition codes. Use of L5999 is incorrect coding 
(unbundling). You can find this in the Local Coverage Article: Lower Limb Prostheses - Policy Article 
(A52496). 
 
The payment amount for a given service or item, whether rented or purchased, must be consistent with what is 
reasonable and medically necessary to serve the intended purpose (See the Medicare Benefit Policy Manual, 
Chapter 15). Additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic 
reasons or added convenience, do not meet the reasonableness test. Thus, where a service or item is medically 
necessary and covered under the Medicare program, and the patient wishes to obtain such deluxe features, the 
payment is based upon the payment amount for the kind of service or item normally used to meet the intended 
purpose (i.e., the standard item.) You can find this information in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 20, 
page 42. 
 
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 an ultrasonic osteogenesis stimulator (E0760) is covered only if all of the following criteria 
are met: 
 
        Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting 
treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph set must 
include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner 
stating that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs; and 
        The fracture is not of the skull or vertebrae; and 
        The fracture is not tumor related. 
 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if any of the criteria above are 
not met. 
 
Use of an ultrasonic osteogenesis stimulator for the treatment of a fresh fracture or delayed union will be 
denied as not medically necessary. 
 
Ultrasound conductive coupling gel is covered and separately payable if an ultrasonic osteogenesis stimulator 
is covered. 
 
An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other 
noninvasive osteogenesis stimulators. 
 
You can find this information in the Local Coverage Determination (LCD) Osteogenesis Stimulators L33796. 
 
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.