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 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 N means packaged items and services packaged 
into APC rates paid under OPPS; payment is packaged into payment for other services. Therefore, there is no 
separate APC 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 23, 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 say that the indications for surgical treatment of varicose veins are: 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, and 
2. The patient is symptomatic, and has one or more of the following: 
 
a. Pain or burning in the extremity severe enough to impair mobility 
b. Recurrent episodes of superficial phlebitis  
c. Non-healing skin ulceration  
d. Bleeding from a varicosity  
e. Stasis dermatitis  
f. Refractory dependent edema 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Varicose Veins of the Lower 
Extremities (L34209) - Effective December 1, 2019. 
 
The rules say that the indications for endovenous radiofrequency ablation/laser ablation (ERFA/LA), are in 
addition to the above, the patient's anatomy and clinical condition are amenable to the proposed treatment 
including ALL of the following: 
 
1. Absence of aneurysm in the target segment. 
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 
4. The absence of significant peripheral arterial diseases. 
 
You can find this rule in the Local Coverage Determination (LCD) - Treatment of Varicose Veins of the Lower 
Extremities (L34209) - Effective December 1, 2019. 
 
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 you are covered for hearing aids from a provider in the Plan's hearing aid vendor's 
network. You are responsible for all costs for hearing aids not purchased from a hearing network provider. You 
can find this information on pages 4-20 to 4-22 of the Plan's 2021 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 Guardant360 remains covered for patients with non-CNS originated solid tumors who 
meet the criteria of NCD 90.2 when the following conditions are met: 
Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did 
not originate from the central nervous system. Patients who would meet all of the indications on the FDA label 
for larotrectinib if they are found to have an NTRK mutation may be considered to have advanced cancer, and 
 Patient has not previously been tested with the Guardant360 test for the same primary cancer. For a 
patient who has been tested previously using Guardant360 for a cancer, that patient may only be 
tested again when the patient has a new primary cancer diagnosis. In a patient with previously tested 
primary cancer, who has evidence of new malignant growth, that growth may be considered to be a 
different primary cancer if it does not originate from the same cell line or it is physiologically different 
enough that it responds differently to treatment than the previously tested cancer, and 
 Patient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. 
progression or new lesions on treatment), and 
 The patient has decided to seek further cancer treatment with the following conditions: 
 The patient is a candidate for further treatment with a drug that is either FDA-approved for that 
patients cancer, or has an NCCN 1 or NCCN 2A recommendation for that patients cancer, and 
 The FDA-approved indication or NCCN recommendation is based upon information about the 
presence or absence of a genetic biomarker tested for in the Guardant360 assay, and 
 Tissue-based CGP is infeasible (i.e., 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 at Local Coverage Article (LCA) A58192: Billing and Coding: Guardant360 (eff. 
5/15/20). 
 
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 determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level two ambulator has the ability or potential for ambulation with the ability to traverse 
low level environmental barriers such as curbs, stairs or uneven surfaces. This is typical of the community 
ambulator. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that a flexible-keel foot (L5972) is covered for beneficiaries whose functional level is 2 or above. 
You can find this rule in the Local Coverage Determination (LCD) - Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
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 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. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 107 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 state that the following provider types are eligible to furnish mental health services under Medicare 
rules: Physicians, Clinical Psychologists, Clinical Social Workers, Clinical Nurse Specialists, Nurse 
Practitioners, Physician Assistants, Certified Nurse-Midwives, Independently Practicing Psychologists, and 
Certified Registered Nurse Anesthetists.  No other provider types are eligible. You can find this rule at Centers 
for Medicare and Medicaid Services, MedLearn Matters Booklet on Medicare Mental Health, MLN 1986542. 
 
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 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). 
 
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 eye refractions are only covered during a routine exam with a participating vision care provider. You 
can find this information on page 108 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 state that testing for the FANCC gene is not a Medicare benefit and is a statutorily excluded service. 
In addition to single gene testing, MolDX will also deny panels of tests that include the FANCC gene. This rule 
is found in Local Coverage Article: Billing and Coding: MolDX: FANCC Genetic Testing (A53628). 
 
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 covered cerebrovascular arterial study testing methods include (real-time) duplex scans; and 
Doppler ultrasound waveform with spectral analysis. 
 
Non-covered/non-reimbursed methods include testing methods that have not been found to be useful based on 
authoritative technological assessments or that are included as part of the physical examination. 
 
The indications for cerebrovascular arterial studies may be considered medically necessary if one or more of 
the following signs and symptoms are present: 
Asymptomatic or symptomatic cervical bruits; 
Amaurosis fugax; 
Focal cerebral or ocular transient ischemic attacks (including but not limited to): 
   localizing symptoms, e.g., sensory loss; and/or 
   weakness of one side of the face; and/or 
   slurred speech; and/or 
   weakness of a limb; 
Syncope that is strongly suggestive of vertebrobasilar or bilateral carotid artery disease in etiology, as 
suggested by medical history; 
Recent history of a previous neurologic or cerebrovascular event; 
Before major cardiac and vascular surgery when a bruit is noted, there is history of previous neurologic or 
cerebrovascular event, or there is documented clinical suspicion of extracranial carotid occlusion and the 
rationale for the study is included in the chart; 
After carotid endarterectomy (outside the global period), or follow-up of previously documented stenoses; 
Pulsatile neck mass; 
Evaluation of blunt or penetrating neck trauma; 
Ocular microembolism (optic nerve/retinal arterial-Hollenhorst plaques/ocular) 
 
You can find this information in the Local Coverage Determination (LCD): Non-Invasive Vascular Studies 
(L33627). 
 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 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 CPT codes 82607 and 84207 have diagnosis code limitations. You can find this information 
in the Local Coverage Article (LCA): Assays for Vitamins and Metabolic Function (A56416). 
 
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 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). 
 
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 you must pay a $25 copayment for specialist's office visits for Medicare Covered vision services. The 
Plan contract says that the network of providers for your supplemental vision benefits may be different than the 
network of providers for the Original Medicare vision benefits listed. The contract also says when using an out-
of-network provider, you will be responsible for costs above the plan approved amount. You are responsible 
for submitting an approved Vision vendor Care out-of-network claim form with itemized receipt when seeing a 
non-Plan approved vision provider. You can find this information on pages 90 and 94 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 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 providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-T9, 
E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. You can 
find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9.3.2. 
 
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 radiology and other diagnostic services furnished to hospital outpatients are paid under the 
Outpatient Prospective Payment System (OPPS) to the hospital. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 13, Section 20.2.1. 
 
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 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 anesthesia procedures listed in the CPT/HCPCS Codes section of the related Local 
Coverage Article Billing and Coding: Monitored Anesthesia Care (A57361), are examples of those that are 
usually provided by the attending surgeon and are included in the global fee and are not separately billable. In 
certain instances, MAC provided by anesthesia personnel may be reasonable and necessary for procedures that 
are generally provided by the attending surgeon if certain conditions or situations are present. In these 
situations, MAC may be necessary for these active and serious accompanying situations or conditions to ensure 
smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. Refer to the related 
billing and coding article for diagnoses that support the use of MAC in these situations. Special conditions or 
criteria must be supported by documentation in the medical record. You can find this rule in Local Coverage 
Determination (LCD) Monitored Anesthesia Care L35049. 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. An exact duplicate for physician and other supplier claims is a claim that exactly matches 
another claim or claim line with respect to, among other items, provider number, date of service, procedure 
code, place of services, and billed amount. 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 1, Section 120.2. 
 
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.