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 modifiers -HA through -HZ are not covered or not payable by Medicare. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 1, Section 60.4.2. 
 
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 says that Medicare will consider total knee arthroplasty (TKA) medically reasonable and necessary 
when three or more of the following criteria are met: 
1. Advanced joint disease demonstrated by radiographic supported evidence or magnetic resonance 
imaging (MRI), e.g., fracture or deterioration, distortion of joint surfaces, subchondral cysts, 
subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular 
necrosis; 
2. History of unsuccessful appropriate conservative therapy that is clearly documented in the pre-
procedure medical record. Non-surgical medical management is usually implemented for 3 months or 
more to assess effectiveness. Conservative treatment as clinically appropriate for the patients current 
episode of care typically includes one or more of the following: anti-inflammatory medications; 
analgesics; flexibility and muscle strengthening exercises with supervised physical therapy. 
3. Pain with functional disability due to arthritis or trauma to the knee joint; activities of daily living 
(ADLs) are diminished despite compliance with plan of care including activity restrictions as is 
reasonable, assistive device use, weight reduction as appropriate or therapeutic injections into the knee 
as appropriate; 
4. Distinct structural abnormalities such as: 
- Distal femur fracture; 
- Proximal tibia fracture; 
- Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; 
- Avascular or other form of osteonecrosis of the knee; 
- Rheumatologic changes precluding or inconsistent with rehabilitation 
5. Failed previous joint replacement/arthroplasty necessitating revision as indicated by any of the 
following: 
- Loosening, fracture, or mechanical failure of one or more components; 
- Technical or functional failure of previous knee surgery, e.g. unicompartmental knee 
replacement; 
- Previous osteotomy or partial arthroplasty; 
- Infection; - Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella; Implant or knee 
malalignment; 
- Bearing surface wear leading to symptomatic synovitis; 
- Tibiofemoral or extensor mechanism instability; or 
- Knee stiffness, arthrofibrosis or other destructive conditions that render the knee impaired to the 
extent to preclude employment or functional activities. 
You can find this information in Local Coverage Determination (LCD): Lower Extremity Major Joint 
Replacement (Hip and Knee) (L36007). 
 
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 emergency department coding is not appropriate if the site of service is an office or 
outpatient setting or any sight of service other than an emergency department. The emergency department 
codes should only be used if the patient is seen in the emergency department and the services described by the 
HCPCS code definition are provided. The emergency department is defined as an organized hospital-based 
facility for the provision of unscheduled or episodic services to patients who present for immediate medical 
attention. You can find this rule in the Medicare Claims Processing Manual Chapter 12, Section 30.6.11. 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
 
   a. Patient has: 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
not been previously tested with the same test using NGS for the same cancer genetic content, and 
decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have: 
Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
an FDA-approved or -cleared indication for use in that patients cancer; and, 
results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this information in the National Coverage Determination (NCD) Next Generation Sequencing 
(NGS) 90.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that coverage of neuromuscular electrical stimulator (NMES) to treat muscle atrophy is limited 
to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or 
splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery 
(until orthotic training begins). Coverage for NMES/functional electrical stimulator (FES) for walking will be 
covered in spinal cord injury (SCI) patients with all of the following characteristics: 
1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); 
2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can 
demonstrate balance and control to maintain an upright support posture independently; 
3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical 
stimulation sufficient for muscle contraction; 
4. Persons that possess high motivation, commitment and cognitive ability to use such devices for 
walking; 
5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 
3 minutes; 
6. Persons that can demonstrate hand and finger function to manipulate controls; 
7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery; 
8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to 
osteoporosis; and 
9. Persons who have demonstrated a willingness to use the device long-term. 
 
You can find these rules in National Coverage Determination (NCD) Neuromuscular Electrical Stimulation 
(NMES) (160.12). 
 
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 equipment which the beneficiary owns or is a capped rental item may be replaced in cases of 
loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster. Irreparable 
wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be 
identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful 
lifetime of the equipment. Carriers may determine the reasonable useful lifetime of equipment, but in no case 
can it be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment. You can find these rules in Medicare Benefit Policy Manual Chapter 15, Section 110.2(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
Please note, the Local Coverage Article (LCA), A58710, the Plan used in their decision to deny services was 
not used in our determination. The medical records show that the services at issue were provided in 
Mississippi. The LCA 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(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 prior to or at the time of delivery of a power operated vehicle (POV) or power wheelchair 
(PWC), the supplier or practitioner must perform an on-site evaluation of the beneficiarys home to verify that 
the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway 
width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request. 
You can find this information in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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 PVA (percutaneous vertebroplasty (PVP) or 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 VCF (T1  L5), based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/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)  
i. All patients presenting with VCF should be referred for evaluation of 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 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy b. Relative contraindication 
I. Greater than three vertebral fractures per procedure 
II. Allergy to bone cement or opacification agents 
III. Uncorrected coagulopathy 
IV. Spinal instability 
V. Myelopathy from the fracture 
VI. Neurologic deficit 
VII. Neural impingement 
VIII. Fracture retropulsion/canal compromise 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33569: Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF). 
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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has 
sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; 
and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the 
criteria below: 
   A. The beneficiary is insulin-treated; or, 
   B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
following: 
      -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
            medication(s) and/or modify the diabetes treatment plan; or, 
      -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state 
requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-
approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-
(4) above are met. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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 incontinence supplies are not covered because they are hygienic items that are non-reusable. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.1. 
 
Other supplies used in the management of incontinence, including but not limited to the following items, will 
be denied as non-covered because they are not prosthetic devices nor are they required for the effective use of a 
prosthetic device:  
 
-Creams, salves, lotions, barriers (liquid, spray, wipes, powder, paste) or other skin care products (A6250)  
 
You can find this rule in the Local Coverage Article (LCA): Urological Supplies (A52521). 
 
The rules say that non-sterile gloves are not covered because they are hygienic items that are non-reusable. You 
can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 
100-03, Medicare National Coverage Determinations (NCD) Manual, Section 280.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 the patient's medical record should contain documentation that fully supports the medical 
necessity for intra-articular injections of sodium hyaluronate (Hyalgan, Supartz or Visco-3TM, EuflexxaTM, 
MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 
(Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), high molecular weight hyaluronan (Orthovisc) 
and high molecular weight viscoelastic hyaluronan (Hymovis). This documentation includes, but is not 
limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or 
procedures, and history of pharmacologic therapy. Documentation of subsequent courses of treatment must 
clearly establish reduction of patient symptomatology and medication usage. This documentation must be 
submitted upon request. Claims submitted without requested supporting evidence in the medical record will be 
denied as being not medically necessary. You can find this information in the Local Coverage Article: Billing 
and Coding: Hyaluronans Intra-articular Injections of (A52420). 
 
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 the EnvisiaTM classifier is reasonable and necessary when all of the following conditions are 
met: 
 
   - That are healthy enough to undergo a bronchoscopy with TBBs, and 
   - HRCT scan of the chest (defined by high kernel ~1mm axial reconstructions, including both inspiratory and 
expiratory imaging) showing 1 of the following: 
       -- A Probable UIP pattern (see comment below) as defined by the 2018 Fleichner Society White paper 
(https://www.ncbi.nlm.nih.gov/pubmed/29154106 
       -- An "Indeterminate for UIP pattern as defined by the 2018 Fleichner Society White paper 
(https://www.ncbi.nlm.nih.gov/pubmed/29154106  
   - Exclusion of autoimmune disease by clinical evaluation and serologic testing, including, when indicated, an 
evaluation by a rheumatologist 
   - Absence of a definitive occupational, environmental, medication-related, or other cause of the patients lung 
disease. 
 
You can find this rule in the Local Coverage Determination (LCD) for MolDX: EnvisiaTM, VeracyteTM, 
Idiopathic Pulmonary Fibrosis Diagnostic Test (L37887). 
 
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.