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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The rules say 
functional blepharoplasty procedures and surgical procedures of the brow will be considered medically 
reasonable and necessary in the following situations: 
1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by 
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors
1
 or; 
2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to 
any of the following: 
 Dermatochalasis
1
 
o Blepharochalasis
1
 
o Blepharoptosis
1,2
 
o Brow ptosis causing malposition of the upper eyelid
1
 and demonstrating a MRD1 (Margin reflex 
distance) of 2 mm or less
3
 
o Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
o Pseudoptosis
1
 
o When there is visual impairment secondary to redundant skin weighing down on upper 
lashes
1
 resulting in eye strain, headache and loss of vision.
2,4,5
 o When there is chronic, symptomatic dermatitis
3
 of pretarsal skin
1
 caused by redundant upper lid 
skin which has not been successfully treated by conservative measures such as education 
regarding hygiene, antibiotics, etc.; or 
3. Visual field testing demonstrating a 12-to-15-degree superior field loss or 24% to 30% superior visual 
field impairment
3
; or 
4. When there is the presence of prosthesis difficulties in an anophthalmic socket
3,6
; or 
5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation 
and inflammation and excessive tearing
2
; or 
6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are 
contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation
2
; or 
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion.
1,2
 
You can find this information in Medicares Local Coverage Determination (LCD)  Blepharoplasty, 
Blepharoptosis Repair and Surgical Procedures of the Brow (L34028).
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 60 one-way trips per year. You can find this information on page 91 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 state that to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. However, do not pay for repair of previously denied equipment or equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds 
the estimated expense of purchasing or renting another item of equipment for the remaining period of 
medical need, no payment can be made for the amount of the excess. 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. 
 
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. 
 
The rules say that Medicare will pay for normally excluded dental services or related services in limited cases. 
Medicare will pay for this non-routine dental care: 
- An excluded dental service if it is performed by a dentist as incident to and as an integral part of a covered 
service performed by the same dentist on the same day. This exception does not apply if the excluded service is 
the primary service performed by the dentist.   
- Services for wiring of the teeth if done in connection with a jaw fracture. 
- A dental examination done in the hospital if it is part of a work-up prior to kidney transplant surgery. 
- Services for extraction of the teeth if done to prepare the jaw for radiation treatment needed as a result of 
cancer.   
 
You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 150 and Chapter 16, 
Section 140 and in the National Coverage Determinations Manual, Chapter 1, Section 260.6. 
 
The rules say that Medicare will pay for normally excluded dental services or related services in limited cases. 
Medicare will pay for inpatient hospital services furnished in connection with an excluded dental service if a 
hospital stay is needed because of the persons underlying medical condition or because of the complexity of 
the dental service. Medicare will pay for the inpatient hospital services but will not pay for the services of 
physicians furnished in connection with the excluded dental services. You can find these rules in the Medicare 
Benefit Policy Manual, Chapter 1, Section 70. 
 
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 medically accepted off-label uses for Food and Drug Administration 
(FDA) approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of 
compendia which define if a use is medically accepted. The off-label use must be supported in one or more of 
these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one 
or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or 
equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state 
to be reasonable and necessary. You can find these rules and the list of the Medicare-recognized compendia in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 50.4.5. 
 
The rules say that upon review, if the drug use is not on the FDA label, does not appear on the American 
Hospital Formulary Services (AHFS), Elsevier/Gold Standard Clinical Pharmacology, NCCN Drugs and 
Biologics Compendium, Truven Health Analytics Micromedex DrugDex and/or Wolters Kluwer Lexi-
Drugs compendium or National Government Services has not published an LCD or article covering the off-
label use as listed below, then the drug use is not approved and the use of the drug may be denied. However, 
determinations as to whether medication is reasonable and necessary for an individual patient may be made on 
appeal on the same basis as all other such determinations (i.e., with support from the peer-reviewed literature, 
with the advice of medical consultants, with reference to accepted standards of medical practice, and in 
consideration of the medical circumstance of the individual case). You can find this information in the Local 
Coverage Determination (LCD) L33394: Drugs and Biologicals, Coverage of, for Label and Off-Label Uses. 
 
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 modifier 54 is to be used to indicate when the surgeon transfers all or part of the post-
operative care to a provider outside their group.  This modifier applies when the surgeon fully transfers critical 
care services to another provider. You can find this rule at Centers for Medicare and Medicaid Services, J5 
WPS Government Health Administrators bulletin entitled "Modifier 54 Fact Sheet." 
 
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. The health plan contract 
covers various dental services as supplemental benefits. The health plan contract lists which services are 
covered. You can find this information on pages 62 to 64 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 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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. Periodontal scaling and root planing is covered by the Plan's dental benefits. You can find this 
information on pages 75 to 78 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 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 evaluation and management services on the day before major surgery or on the day of major 
surgery that result in the initial decision to perform the surgery are not included in the global surgery payment 
for the major surgery and, therefore, may be billed and paid separately. In addition to the CPT evaluation and 
management code, modifier "-57" (decision for surgery) is used to identify a visit which results in the initial 
decision to perform surgery. 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 40.2.A(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 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. 
 
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 for people at high risk of colorectal cancer, the Plan covers a screening colonoscopy (or screening barium 
enema as an alternative) every 24 months. You can find this information on page 58 of the Plan's 2023 
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 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. You can find this rule in the Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L35160). 
 
The rules say that to report a Breast Cancer Index (BCI) service, the following claim information should be 
submitted: select CPT code 81518, enter unit of service (UOS), enter the appropriate DEX Z-CodeTM identifier 
adjacent to the CPT code in the appropriate field for the claim type; and select the appropriate ICD-10 CM 
code. You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Article: Billing and Coding: MolDX: Breast Cancer Index (BCI) Gene Expression Test (A57773). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles, and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $35 copayment for in-network provider and professional services 
provided in a specialists office. You can find this information on page 83 of the Plan's 2022 Evidence of 
Coverage (EOC), and page 73 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
Please note, the Local Coverage Determination, L36807, the Plan used in their decision to deny services is not 
binding in this case. The rule does not have jurisdiction where the services were provided. 
 
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 comprehensive genomic profile next-generation sequence (CGP NGS) testing for patients 
with advanced cancer is reasonable and necessary only when performed in a CLIA-certified laboratory, when 
ordered by a treating physician, and when the patient has: 
 
 either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer; and 
 not been previously tested with a CGP for the same cancer genetic content; and 
 decided to seek further cancer treatment (e.g., therapeutic chemotherapy) 
 
Additionally, the test performed must be able to detect at least the minimum genes and genomic positions 
required for the identification of clinically supported, FDA-approved therapies. The genes and genomic 
positions required are listed in Category 1 or 2A of the most current version of the National Comprehensive 
Cancer Network (NCCN) Biomarkers Compendium (2). Testing assays must be FDA approved/cleared, or if a 
laboratory developed test (LDT), have a published, peer-reviewed study supporting analytic validity, or 
certification by a third-party consistent with the New York State Department of Healths Clinical Laboratory 
Evaluation Program (CLEP) review standards. 
 
 
 Documentation must be adequate to verify that coverage guidelines listed above have been met. Thus, the 
medical record must contain documentation that the testing is expected to influence treatment of the condition 
toward which the testing is directed. The laboratory or billing provider must have on file the physician 
requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s). Any 
diagnosis code not listed does not support medical necessity. 
 
You can find this rule in the Local Coverage Determination and Article for Genomic Sequence Analysis Panels 
in the Treatment of Solid Organ Neoplasms, L37810 and A56867 
 
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.