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). 
 
Medicare guidance says that if one laboratory procedure evaluates multiple genes using a next generation 
sequencing 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 CPT code. If no CPT code accurately describes the procedure performed, the laboratory 
may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report 
multiple individual CPT codes describing the component test results when medically reasonable and necessary. 
Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) 
and ordered by the physician who is treating the beneficiary and using the results in the management of the 
beneficiary's specific medical problem. If a single procedure is performed, only one HCPCS/CPT code with 
one unit of service may be reported for the procedure. You can find this Medicare guidance in the Medicare 
National Coverage Determination: Next Generation Sequencing (NGS) 90.2 and Medicare NCCI Coding 
Policy Manual  Chapter 10  CPT Codes  80000-89999. 
 
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 cervical disc replacement is considered investigational when there has been a previous 
fusion at another level. You can find this rule in Local Coverage Determination (LCD): Cervical Disc 
Replacement (L38033). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare guidance says, Physicians must report services correctly. This manual discusses general coding 
principles in Chapter I, and principles more relevant to other specific groups of HCPCS/CPT codes in the other 
chapters. There are certain types of improper coding that physicians must avoid. All practitioner claims 
submitted to MACs, outpatient facility services claims (Type of Bill 13X, 14X, 85X), and supplier claims 
submitted to Durable Medical Equipment (DME) MACs are tested against MUEs for HCPCS codes with an 
MAI of "2" are absolute date of service edits. These are "per day edits based on policy". HCPCS codes with an 
MAI of "2" have been rigorously reviewed and vetted within CMS and obtain this MAI designation because 
UOS on the same date of service (DOS) in excess of the MUE value would be considered impossible because it 
was contrary to statute, regulation, or sub regulatory guidance. This sub regulatory guidance includes clear 
correct coding policy that is binding on both providers and CMS claims processing contractors. Limitations 
created by anatomical, or coding limitations are incorporated in correct coding policy, both in the HIPAA 
mandated coding descriptors and CMS approved coding guidance as well as specific guidance in CMS and 
NCCI manuals. For example, it would be contrary to correct coding policy to report more than one unit of 
service for CPT 94002 (Ventilation assist and management . . . initial day) because such use could not 
accurately describe two initial days of management occurring on the same date of service as would be required 
by the code descriptor. As a result, claims processing contractors are instructed that an MAI of "2" denotes a 
claims processing restriction for which override during processing, reopening, or redetermination would be 
contrary to CMS policy. Edits based on established CMS policies may limit UOS. For example, a) The MUE 
value for a surgical or diagnostic procedure may be based on the bilateral surgery indicator on the Medicare 
Physician Fee Schedule Database (MPFSDB). ii. If the bilateral surgery indicator is "1", a bilateral surgical 
procedure must be reported with "1" unit of service and modifier 50 (bilateral modifier). You can find this 
guidance in the National Correct Coding Initiative Chapter 1, A. Introduction and V. Medically Unlikely Edits 
(MUEs). Medicare guidance says, HCPCS/ CPT Code: 64494 Practitioner Services MUE Values: 1 MUE 
Adjudication Indicator: 2 Date of Service Edit: Policy. You can find this guidance in the MCR MUE Practitioner Services Eff 01-01-2021. Medicare guidance says, HCPCS - 64494; Bilat Surg- 1. You can find 
this guidance in the 2021 National Physician Fee Schedule. 
 
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 a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s).  
 
The rules also say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a 
beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that 
Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the 
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer 
test). Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above 
criteria for coverage. You can find this rule at Local Coverage Determination (LCD): Knee Orthoses (L33318). 
 
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. 
 
Medicare Guidance says that providers must attempt to consult the attending or primary care physician about 
the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. You can find this Medicare guidance in the Code of Federal 
Regulation 42 CFR  410.71 - Clinical psychologist services and services and Medicare MLN Booklet - 
MEDICARE MENTAL HEALTH  https://www.cms.gov/files/document/medicare-mental-health. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
Medicare guidance says: a narrative explanation of unlisted CPT codes must be on the claim or attached to the 
claim. The provider's staff is responsible for submitting information to the health plan for review and 
determination. You can find this Medicare Local Coverage Article: Medicare Claims Processing Manual, Pub 
100-04, Chapter 26, Medicare Program Integrity Manual, Chapter 3 - Section 3.3.2.1, NCCI Policy Manual for 
Medicare Services, Chapter 1, General Correct Coding Policies, and Medicare Claims Processing Manual. 
 
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 of PNS trials requires that patients have all of the following: 
 Documented chronic and severe pain for at least 3 months, 
 Documented failure of less invasive treatment modalities and medications, 
 Lack of surgical contraindications including infections and medical risks, 
 Appropriate proper patient education, discussion and disclosure of risks and benefits, 
 No active substance abuse issues, 
 Formal psychological screening by a mental health professional, and 
 Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before 
permanent implantation. 
You can find this rule at Local Coverage Determination (LCD) L37360: Peripheral Nerve Stimulation (eff. 
12/1/19). 
 
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 coverage of PNS trials requires that patients have all of the following: 
 Documented chronic and severe pain for at least 3 months, 
  
   Documented failure of less invasive treatment modalities and medications, 
 Lack of surgical contraindications including infections and medical risks, 
 Appropriate proper patient education, discussion and disclosure of risks and benefits, 
 No active substance abuse issues, 
 Formal psychological screening by a mental health professional, and 
 Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before 
permanent implantation. 
 
You can find this rule at Local Coverage Determination (LCD) L37360: Peripheral Nerve Stimulation (eff. 
12/1/19). 
 
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 supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the 
treating physician before dispensing any DMEPOS item to a beneficiary. All DMEPOS items other than those 
referenced in 42 CFR 410.38(c)(4) and 410.38(g)(2) require detailed written orders prior to billing. Detailed 
written orders may take the form of a photocopy, facsimile image, electronically maintained, or original "pen-
and-ink" document. (See chapter 3, 3.3.2.4). The written order must be sufficiently detailed, including all 
options or additional features that will be separately billed or that will require and upgraded code. The 
description can be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model 
number. All orders must clearly specify the start date of the order. A written order prior to delivery is required 
for certain DMEPOS items as specified in 42 CFR 410.38(c)(4) and 410.38(g)(2). For these items, the supplier 
must have received a written order that has been both signed and dated by the treating physician/practitioner 
before dispensing the item. If a supplier bills for an item without a written order prior to delivery, the item will 
be denied. For a covered DME item, outlined in 42 CFR 410.38(g), the contractor shall ensure that the item of 
DME ordered, the NPI of the prescribing physician/practitioner, the signature of the prescribing 
physician/practitioner and the date of the order. If this information is not included on the written order, the 
claim will be denied. Medicare requires that the written order is completed after the face-to-face encounter. If 
the date of the written order is prior to the date of the face-to-face encounter, the contractor shall deny the 
claim. You can find this information in the Medicare Program Integrity Manual, Chapter 5 - Items and Services 
Having Special DME Review Considerations, Section 5.2.1- Physician Orders, Section 5.2.3 - Detailed Written 
Orders and Section 5.2.4 - Written Orders Prior to Delivery, Paragraph A. General and Paragraph C. - Written Orders for Certain Covered Durable Medical Equipment (DME) items; and Section 5.8- Supplier 
Documentation; and the Medicare Program Integrity Manual, Chapter 4- Program Integrity, Section 4.26.1- 
Proof of Delivery and Delivery Methods. 
 
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 the Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-
valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following 
conditions: 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: The patient must have: A CHADS2 score = 2 (Congestive heart failure, Hypertension, Age >75, 
Diabetes, Stroke/transient ischemia attack/thromboembolism) or CHA2DS2- VASc score = 3 (Congestive heart 
failure, Hypertension, Age = 65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular 
disease, Sex category) 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. 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 information in the National Coverage Determination 
(NCD) Percutaneous 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 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 Plan 
contract says that Part B drugs may be subject to step therapy requirements. You can see this on page 92 of the 
Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 15, Section 15.1.  
 
The rules also say that there are some types of provider who are not eligible to enroll in the Medicare program. 
Among these are licensed professional counselors and marriage and family therapists. You can find this in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program 
Integrity Manual, Chapter 10, Section 10.1.8. 
 
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 effective for dates of service specified below, the Centers for Medicare & Medicaid Services 
(CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for 
beneficiaries with LSS who are enrolled in an approved clinical study that meets specific criteria. 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 150.13. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare guidance says that providers must attempt to consult the attending or primary care physician about 
the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. You can find this Medicare guidance in the Code of Federal 
Regulation 42 CFR Section 410.71 - Clinical psychologist services and services and Medicare MLN Booklet -
MEDICARE MENTAL HEALTH. 
 
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 the general term CGM refers to both therapeutic/non-adjunctive and non-
therapeutic/adjunctive CGMs. For the purpose of this LCD, the term therapeutic may be used 
interchangeably with the term non-adjunctive. Likewise, the term non-therapeutic may be used 
interchangeably with the term adjunctive. 
 
A therapeutic or non-adjunctive CGM can be used to make treatment decisions without the need for a stand-
alone BGM to confirm testing results. A non-therapeutic or adjunctive CGM requires the user verify their 
glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions. On February 
28, 2022, the Centers for Medicare and Medicaid Services determined that both therapeutic/non-adjunctive and 
non-therapeutic/adjunctive CGMs may be classified as durable medical equipment (DME). Adjunctive CGM 
devices do not replace a standard home BGM. The supply allowance for an adjunctive CGM (A4238) 
encompasses all items necessary for the use of the device and includes but is not limited to, CGM sensors and 
transmitters.   
 
The rules also say that continuous glucose monitors (CGMs) and related supplies are covered by Medicare 
when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
   2. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump, 
  3. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results. 
  4. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
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.