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 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 86 to 87 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 all the following must be present for coverage eligibility: 
 The patient must have:  
o Any cancer diagnosis 
o AND a clinical indication for germline (inherited) testing for hereditary cancer 
o AND a risk factor for germline (inherited) cancer  
o AND has not been previously tested for the same germline genetic content. 
 The test has satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services 
Program (MolDX) for the stated indications of the test. 
 The test performed includes at least the minimum genetic content (genes or genetic variants) with 
definitive or well-established guidelines-based evidence required for clinical decision making for its 
intended use that can be reasonably detected by the test.  
o Because these genes and variants will change as the literature and drug indications evolve, they 
are listed separately in associated documents, such as the MolDX TA forms.  
o A single gene or variant may be tested if it is the only gene or variant considered to be 
reasonable and necessary for a cancer type.  
 If a previous test was performed with a similar/duplicative intended use, a subsequent test is only 
reasonable and necessary if the non-duplicative genetic content of the second test is reasonable and 
necessary. 
 If the test is an NGS test, it must abide by all conditions listed in the NCD 90.2. 
You can find this rule in Local Coverage Determination (LCD) MolDX: Lab-Developed Tests for Inherited 
Cancer Syndromes in Patients with Cancer L38966. 
 
 The rules say that screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
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 at this time, all claims submitted for laboratory tests subject to Clinical Laboratory 
Improvement Amendments (CLIA) are edited at the CLIA certificate level. However, the Healthcare Common 
Procedure Coding System (HCPCS) codes that are considered a laboratory test under CLIA change each year. 
The CMS identifies the new HCPCS (non-waived, non-provider-performed procedure) codes, including any 
modifiers that are subject to CLIA edits by providing an updated listing of these tests to the A/B Medicare 
Administrative Contractors (MACs) (A) and (B) on an annual basis via a Recurring Update Notification. A 
facility that submits a claim for any test mentioned in the HCPCS codes that are subject to CLIA edits list must 
have either a valid, current CLIA certificate of registration (certificate type 9), a CLIA certificate of compliance 
(certificate type 1), or a CLIA certificate of accreditation (certificate type 3). Information regarding CLIA test 
complexity categorization can be found by searching the U.S. Food and Drug Administration website 
(www.fda.gov). In addition, the CMS identifies the new HCPCS codes in the 80000 series that are excluded 
from CLIA edits by providing an updated listing of these tests to the A/B MACs (A) and (B) on an annual basis 
via a Recurring Update Notification. No CLIA certificate is required for a claim submitted for any test 
mentioned in the HCPCS codes in the 80000 series that are excluded from CLIA edits list. You can find this 
information in the Medicare Claims Processing Manual, Chapter 16 - Laboratory Services, Section 70.9 - 
HCPCS Subject To and Excluded From CLIA Edits. 
 
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 SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable 
and necessary. You can find this information in Medicare's Local Coverage Determination (LCD): Sacroiliac 
Joint Injections and Procedures (L39464). 
 
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 a Medicare plan may restrict enrollees 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 an enrollees medical needs. You can find this rule at 42 CFR Section 422.112. 
 
The rules say that plans must ensure continuity of care for enrollees. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 4, Section 
110.6. 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the plan ensures that all covered 
services are available and accessible under the plan. The plan must arrange for and cover any medically 
necessary covered benefit outside of the plan provider network, but at in-network cost sharing, when an in-
network provider or benefit is unavailable or inadequate to meet an enrollee's medical needs. Plans offering 
coordinated care plans must ensure continuity of care and integration of services through arrangements with 
contracted providers. This includes services available through contracting or non-contracting providers in the 
area serviced by the health plan including nursing home and community-based services, and behavioral health 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 32 to 33 of the Plans 
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 state that a repeat series of hyaluronan knee injection(s) for patients who have responded to a prior 
series is considered to be reasonable and necessary under the following circumstances: 
-Symptoms have recurred AND, 
-At least six months have elapsed since the prior series of injections AND, 
-There was significant improvement in pain and functional capacity achieved with the prior series of injections 
using a standardized assessment tool OR 
-There is significant reduction in the doses of NSAID medications taken or reduction in the number of intra-
articular steroid injections to the knees during the six-month period following the injection(s). 
 
You can find this rule in the Local Coverage Determination (LCD) for Intraarticular Knee Injections of 
Hyaluronan, L39529. 
 
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 purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS 
code is generally used to reflect the actual setting where the beneficiary receives the faceto-face service. For 
example, if the physicians face-to-face encounter with a patient occurs in the office, the correct POS code on 
the claim, in general, reflects the 2-digit POS code 11 for office. In these instances, the 2-digit POS code (Item 
24B on the claim Form CMS-1500) will match the address and ZIP entered in the service location (Item 32 on 
the 1500 Form)  the physical/geographical location of the physician. However, there are two exceptions to this 
general rule  these are for a service rendered to a patient who is a registered inpatient or an outpatient of a 
hospital. In these cases, the correct POS code -- regardless of where the face-to-face service occurs -- is that of 
the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital 
POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus or on campus) as 
discussed in section 10.5 of this chapter. So, if in the above example, the patient seen in the physicians office 
is actually an inpatient of the hospital, POS code 21, for inpatient hospital, is correct. In this example, the POS 
code reflects a different setting than the address and ZIP code of the practice location (the physicians 
office). You can find this rule in the Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
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 Health Plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules say that the ICD-10-CM has two types of excludes notes. Each type of note has a different definition 
for use, but they are all similar in that they indicate that codes excluded from each other are independent of 
each other. 
a. Excludes1 
A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. An 
Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired 
form of the same condition. 
 
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each 
other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the 
provider. 
For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth grinding 
(G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be 
assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a 
patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are 
clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together. b. Excludes2 
A type 2 Excludes note represents Not included here. An excludes2 note indicates that the condition 
excluded is not part of the condition represented by the code, but a patient may have both conditions at the 
same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the 
excluded code together, when appropriate. You can find this in the International Classification of Diseases 
(ICD)-10-CM Official Guidelines for Coding and Reporting FY 2023 -- UPDATED April 1, 2023. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. The Physician Fee 
Schedule Status Indicator B means that payment for covered services is always bundled into payment for other 
services not specified. There will be no payment amounts for these codes and no separate payment is ever 
made. When these services are covered, payment for them is subsumed by the payment for the services to 
which they are incident. 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, Section 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 only one hospital inpatient or observation discharge day management service is payable per 
patient per hospital stay. You can find this rule in the Center for Medicare and Medicaid Services (CMS) 
Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.2. 
 
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 Current Procedural Terminology (CPT) code 77075 (Radiologic examination, osseous 
survey; complete (axial and appendicular skeleton)) includes radiologic examination of all bones. CPT codes 
for radiologic examination of other bones shall not be reported in addition to CPT code 77075. However, if a  
separate and distinct radiologic examination with additional films of a specific area of the skeleton is 
performed to evaluate a different problem, the appropriate CPT code for the additional radiologic examination 
may be reported with an NCCI-associated modifier. You can find this information in Medicare's Medicare 
National Correct Coding Initiative Policy (NCCI) Manual, Chapter IX Radiology Services CPT Codes 70000 - 
79999, Section C. Non-interventional Diagnostic Imaging. 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of knee. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this information in Medicare's Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 when services are furnished in a mobile unit, they are often provided to serve an entity for 
which another Place of Service (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 information in the Medicare Claims Processing Manual, Chapter 26- Completing 
and Processing Form CMS-1500 Data Set, Section 10.5 - Place of Service Codes (POS) and Definitions- 
Special Considerations for Mobile Unit Settings (Code 15). 
 
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 information in the Medicare Benefit Policy Manual, Chapter 15  Covered Medical and 
Other Health Services, Section 80.4.4 - Exclusions From Coverage as Portable X-Ray Services.  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.