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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules also say that claims or claim lines that have been determined to be exact duplicates of another claim 
or claim line are denied. An exact duplicate for physician and other supplier claims submitted to a MAC or 
carrier is a claim or claim line that exactly matches another claim or claim line with respect to the following 
elements: 
 
   - Medicare beneficiary identifier; 
   - Provider Number; 
   - From Date of Service; 
   - Through Date of Service; 
   - Type of Service; 
   - Procedure Code;    - Place of Service; and 
   - Billed Amount. 
 
You can find this rule in the Center for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 1, Section 120.2. 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
  
  1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
The thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (median 
branch) nerves are considered medically reasonable and necessary for patients who meet ALL the following 
criteria: 
a. Initial thermal radiofrequency ablation (RFA): 
    i. After the patient has had at least two (2) medically reasonable and necessary diagnostic medical branch 
blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary (index) pain 
(with the duration of relief being consistent with the agent used) AND 
    ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and 
necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) 
months or at least 50% consistent improvement in the ability to perform previously painful movements and 
activities of daily living (ADLs) as compared to baseline measurement using the same scale. 
For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 
months. You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L38765). 
 
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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
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). 
 
The rules say that when more than two codes for Pharmacogenomic testing are submitted for the same 
beneficiary on the same date of service, the claims processing system will deny every code submitted after the 
first two services. However, if a lab runs more than two distinct procedural services from this list on a single 
date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it 
is a distinct procedural service. Billing the 59 modifier may result in a request for medical records. You can 
find this information in the Local Coverage Article (LCA): Billing and Coding: Pharmacogenomics Testing 
(A58801). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 A/B MACs (B) must pay for the professional component (PC) of radiology services 
furnished by a physician to an individual patient in all settings under the fee schedule for physician services 
regardless of the specialty of the physician who performs the service. For services furnished to hospital 
patients, A/B MACs (B) pay only if the services meet the conditions for fee schedule payment and are 
identifiable, direct, and discrete diagnostic or therapeutic services to an individual patient, such as an 
interpretation of diagnostic procedures and the PC of therapeutic procedures. The interpretation of a diagnostic 
procedure includes a written report. 
 
A/B MACs (B) must pay under the fee schedule for the technical component (TC) of radiology services 
furnished to beneficiaries who are not patients of any hospital, and who receive services in a physicians office, 
a freestanding imaging or radiation oncology center, or other setting that is not part of a hospital. You can find 
this information in the Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other 
Diagnostic Procedures; 20.1 - Professional Component (PC) and 20.2.2 - Services Not Furnished in Hospitals. 
 
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. 
Viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be 
considered medically reasonable and necessary when ALL of the following conditions are met: 
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of 
daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee 
stiffness. 
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint 
space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due 
to a diagnosis other than osteoarthritis of the knee). 
4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
 Nonpharmacologic therapy (such as but not limited to home exercise program, education, 
weight loss, physical therapy if indicated); and 
 If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan 
product prescribing information. 
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients 
symptoms and intra-articular corticosteroids are not contraindicated. 
You can find this information in the Local Coverage Determination (LCD) Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427). 
 
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 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 therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet ALL the following criteria: 
a. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with 
each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of 
relief being consistent with the agent used); AND 
b. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least consistent 50% 
pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent 
improvement in the ability to perform previously painful movements and ADLs as compared to baseline 
measurement using the same scale; AND 
c. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established 
spinal pseudarthrosis, implanted electrical device) 
You can find this rule in Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management 
L35936. 
 
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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 also says that it offers a supplemental hearing aid benefit.  You must use the Plan's designated vendor 
for this hearing aid benefit. You can find this information on page 76 of the Plan's 2020 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 Guardant360 remains covered for patients with non-CNS originated solid tumors who meet 
the criteria of the National Coverage Determination (NCD) 90.2 when the following conditions are met: 
  
  Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did 
not originate from the central nervous system. Patients who would meet all of the indications on the Food and 
Drug Administration (FDA) label for larotrectinib if they are found to have a Neurotrophic Tyrosine Receptor 
Kinase (NTRK) mutation may be considered to have advanced cancer, and 
Patient has not previously been tested with the Guardant360 test for the same primary cancer. For a 
patient who has been tested previously using Guardant360 for a cancer, that patient may only be tested 
again when the patient has a new primary cancer diagnosis. In a patient with previously tested primary 
cancer, who has evidence of new malignant growth, that growth may be considered to be a different 
primary cancer if it does not originate from the same cell line or it is physiologically different enough 
that it responds differently to treatment than the previously tested cancer, and 
Patient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. 
progression or new lesions on treatment), and 
The patient has decided to seek further cancer treatment with the following conditions: 
The patient is a candidate for further treatment with a drug that is either FDA-approved for that 
patients cancer, or has an NCCN 1 or NCCN 2A recommendation for that patients cancer, and 
The FDA-approved indication or NCCN recommendation is based upon information about the 
presence or absence of a genetic biomarker tested for in the Guardant360 assay, and 
Tissue-based comprehensive genomic profiling (CGP) is infeasible (i.e., quantity not sufficient for 
tissue-based CGP or invasive biopsy is medically contraindicated) or specifically in NSLC Tissue-
based CGP has shown no actionable mutations. 
If no alteration is detected by Guardant360 or if circulating tumor DNA (ctDNA) is insufficient/not detected, 
tissue-based genotyping should be considered. 
You can find this information in the Local Coverage Article, Billing and Coding: Guardant360 (A58192). 
 
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 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 Grievance Manual, Section 50.12.1. 
 
The rules say that Plans are allowed to apply Step therapy to new prescriptions for Medicare Part B covered 
drugs. When implementing this, Plans must establish policies and procedures to educate enrollees concerning 
its step therapy practices. You can find this information in the 42 CFR Section 422.136.  
 
The rules also say that if a Plan decides to adopt and apply step therapy to Part B drugs, the plan must disclose 
that Part B drugs may be subject to step therapy requirements in the plans Annual Notice of Change (ANOC) 
and Evidence of Coverage (EOC) documents. In the EOC, this information must be included in the Medical 
Benefits Chart under Medicare Part B prescription drugs. You can find this information in the Centers for 
Medicare/Medicaid Service (CMS) memorandum entitled Prior Authorization and Step Therapy for Part B 
Drugs in Medicare Advantage. 
 
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 repeat epidural steroid injections are covered when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three months. You can find 
this rule in the Local Coverage Determination (LCD) - Epidural Steroid Injections for Pain Management 
(L39054). 
 
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 all items and non-physician services furnished to inpatients must be furnished directly by the 
hospital or billed through the hospital under arrangements. You can find this rule in the Centers for Medicare 
and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 3, Section 10.4. 
 
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 state that protective outer coverings are not for cosmetic or convenience reasons, or for everyday 
usage in a typical environment. This rule is found in Medicare Local Coverage Article: Lower Limb Prostheses 
- Policy Article (A52496). 
 
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 for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
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 Plan 
contract also says that the Plan covers acupuncture services or chronic low back pain provided by a Primary 
Care Physician (PCP) office visit or a specialist office visit for Medicare-covered services You can find this 
information on page 68 of the Plan's 2021 Evidence of Coverage.