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 state that code 0117U is non-covered for pharmacogenomic testing. You can find this rule in the 
Local Coverage Article (LCA) for Billing and Coding: Pharmacogenomics Testing (A58801). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. Covered dental services are 
listed on pages 61-63 in the Plan's 2023 Evidence of Coverage. Any service not listed is not covered.
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. 
 
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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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients with BOTH the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  
L5) by recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging 
(MRI) or bone-scan/single photon emission computed tomography (SPECT)/computed tomography 
(CT) uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain 
score  8) 
ii. Non-hospitalized with moderate-to-severe pain (NRS or VAS 5) despite optimal non-surgical 
management (NSM) (ONE): 
1. Worsening pain 
2. Stable-to-improved pain (but NRS or VAS still 5) (with  2 of the following): 
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17) 
c. Continuum of care (BOTH): 
1.  
i. All patients presenting with VCF should be referred for evaluation of bone mineral density 
(BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
2. Exclusion criteria (Can have NONE of the following): 
a. Absolute contraindication: 
1.  
i. Current back pain is not primarily due to the identified acute or subacute VCF(s) ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication: 
1.  
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than 3 vertebral fractures 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information in Chapter 4 on pages 61 to 62 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that certain bone mass measurement (BMM) tests are covered when used to screen patients for 
osteoporosis subject to the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit 
Policy Manual. Contractors will pay claims for screening tests when coded as follows: Contains procedure 
code 77078, 77079, 77080, 77081, 77083, 76977 or G0130, and contains a valid diagnosis code indicating the 
reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. 
Contractors are to maintain local lists of valid codes for the benefit's screening categories. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 
13, Section 140.1. 
 
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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. 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 30.3. 
 
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 covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 30 one-way trips and each one-way trip must not exceed 30 miles of driving distance. You can 
find this information on page 89 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that on the 0023 revenue code line, the home health agency (HHA) reports the date of the first 
service provided under the HIPPS code. For other line items detailing all services within the episode period, it 
reports service dates as appropriate to that revenue code. Coding detail for each revenue code under HH PPS is 
defined above under Revenue Codes. For service visits that begin in 1 calendar day and span into the next 
calendar day, report one visit using the date the visit ended as the service date. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Transmittal 2680, Secion 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 Centers for Medicare & Medicaid Services (CMS) covers percutaneous left atrial appendage 
closure (LAAC) for non-valvular atrial fibrillation (NVAF) through Coverage with Evidence Development 
(CED). LAAC devices are covered when the device has received Food and Drug Administration (FDA) 
Premarket Approval (PMA) for that devices FDA-approved indication and meet all of the conditions specified 
below: 
 
1. A CHADS2 score 2 or more (Congestive heart failure, Hypertension, Age > 75, Diabetes, Stroke/transient 
ischemia attack/thromboembolism) or CHA2DS2-VASc score 3 or more (Congestive heart failure, 
Hypertension, Age = 65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular disease, Sex 
category) 
2. A formal shared decision making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the 
shared decision making interaction must be documented in the medical record. 
3. A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the 
conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. 
The patient (preoperatively and postoperatively) is under the care of a cohesive, multidisciplinary team (MDT) 
of medical professionals. The procedure must be furnished in a hospital with an established structural heart 
disease (SHD) and/or electrophysiology (EP) program. 
 
You can find this rule in the National Coverage Determination (NCD) - Percutaenous Left Atrial Appendage 
Closure (LAAC) (20.34). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that when a laboratory assays two or more genes in a patient in parallel. Those two or more 
genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT 
code must be submitted for the panel. This rule is found in the Medicare NCCI Coding Policy Manual  
Chapter 10  CPT Codes  80000-89999, Section F, number 8. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Sections 1861(s)(2)(R) and 1861(pp) of the Social Security Act (the Act) and regulations at 
42 CFR 410.37 authorize Medicare coverage for screening colorectal cancer tests under Medicare Part B. The 
statute and regulations authorize the Secretary to add other tests and procedures (and modifications to tests and 
procedures for colorectal cancer screening) as the Secretary finds appropriate based on consultation with 
appropriate organizations. 
 
The CologuardTM  Multi-target Stool deoxyribonucleic acid (DNA) (sDNA) Test (effective October 9, 2014) 
 
Screening stool or fecal DNA testing detects molecular markers of altered DNA that are contained in the cells 
shed by colorectal cancer and pre-malignant colorectal epithelial neoplasia into the lumen of the large bowel. 
Through the use of selective enrichment and amplification techniques, sDNA tests are designed to detect very 
small amounts of DNA markers to identify colorectal cancer or pre-malignant colorectal neoplasia. The 
CologuardTM  multi-target sDNA test is a proprietary in vitro diagnostic device that incorporates both sDNA 
and fecal immunochemical test techniques and is designed to analyze patients stool samples for markers 
associated with the presence of colorectal cancer and pre-malignant colorectal neoplasia. 
 
Effective for dates of service on or after October 9, 2014, The CologuardTM test is covered once every three 
years for Medicare beneficiaries that meet all of the following criteria: 
 
Age 50 to 85 years, and, 
Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal 
pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal immunochemical test (iFOBT)), 
and, 
At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, 
or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history of colorectal 
cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). 
 
You can find these rules in the National Coverage Determination (NCD) Colorectal Cancer Screening Tests 
210.3. 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 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) (L36021) and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) (A56973).  
 
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 for home health prospective payment system periods of care, the distinct 5-position, 
alphanumeric home health Health Insurance Prospective Payment System (HIPPS) codes are created. The first 
position represents a combination of the referral source (community or institutional) and the period timing 
(early or late). The second and third positions represent the clinical and functional domains of the HHRG 
coding system. The fourth position represents the co-morbidity category that applies to the patient. The fifth 
position is a placeholder for future use, required only because the field used to report HIPPS codes requires five 
positions. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.9. 
 
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 when services are furnished in a mobile unit, they are often provided to serve an entity for 
which another POS code exists. For example, a mobile unit may be sent to a physicians office or a skilled 
nursing facility. If the mobile unit is serving an entity for which another POS code already exists, providers 
should use the POS code for that entity. However, if the mobile unit is not serving an entity which could be 
described by an existing POS code, the providers are to use the Mobile Unit POS code 15. Apply the 
nonfacility rate to payments for services designated as being furnished in POS code 15; apply the appropriate 
facility or nonfacility rate for the POS code designated when a code other than the mobile unit code is 
indicated. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims 
Processing Manual, Chapter 26, Section 10.5. 
 
The rules say that procedures and examinations which are not covered under the portable x-ray provision 
include the following: 
-Procedures involving fluoroscopy; 
-Procedures involving the use of contrast media;  
-Procedures requiring the administration of a substance to the patient or injection of a substance into the patient 
and/or special manipulation of the patient; 
-Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of 
osteopathy or which require that medical judgment be exercised; 
-Procedures requiring special technical competency and/or special equipment or materials; 
-Routine screening procedures; and -Procedures which are not of a diagnostic nature.  
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Benefit Policy Manual- 
Chapter 15, Section 80.4.4. 
 
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 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 pages 59-60 of the Plans 2023 Evidence of Coverage (EOC).