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 state that all the following must be present for coverage eligibility: 
 
    -The patient must have 
        -Any cancer diagnosis 
        -AND a clinical indication for germline (inherited) testing for hereditary cancer 
        -AND a risk factor for germline (inherited) cancer 
        -AND has not been previously tested with 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. 
        -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. 
         -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 information in Local Coverage Determination (LCD): MolDX: Lab-Developed Tests for 
Inherited Cancer Syndromes in Patients with Cancer (L38972). 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 page(s) 27 to 31 of the Plan's 
2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & 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 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 & Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. 
 
Medicare says that there are specific rules for the time spans before and after surgery that are considered part of 
the surgical procedure. This time span is called a Global Surgical Package. The Medicare Fee Schedule Data 
Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. They can be 0 days, 
10 days or 90 days. If there is an indicator of 000, postoperative visits beyond the day of the procedure are not 
included in the payment amount for the surgery.  You can find this rule at Medicare Claims Processing Manual 
Chapter 12 Section 40.1.  
 
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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).

The rules say Modifiers -LT or -RT apply to codes, which identify procedures, which can be performed on
paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers -LT and -RT should be used
whenever a procedure is performed on only one side. Hospitals use the appropriate -RT or -LT modifier to
identify which of the paired organs was operated upon. These modifiers are required whenever they are
appropriate. You can find this rule in the Medicare Claims Processing Manual Chapter 4, Sections 20.6.2 and
20.6.3.

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.
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 non-spinal electrical osteogenesis stimulator (E0747) is covered only if any of the 
following criteria are met: 
1. Nonunion of a long bone fracture (see Appendices section) defined as radiographic evidence 
that fracture healing has ceased for three or more months prior to starting treatment with the 
osteogenesis stimulator, or 
2. Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed 
since the last surgery, or 
3. Congenital pseudarthrosis. 
Nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior 
to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including 
multiple views of the fracture site, and with a written interpretation by a treating practitioner stating that there 
has been no clinically significant evidence of fracture healing between the two sets of radiographs. 
A non-spinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria 
above are met. You can find this rule at Local Coverage Determination (LCD): Osteogenesis Stimulators (eff. 
7/2/23). 
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 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. 
 
You can find this rule in the Local Coverage Determination (LCD) L35936: Facet Joint Interventions for Pain 
Management. 
 
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 a determination of the medical necessity for certain components/additions to the prosthesis 
is based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
 
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
 
You can find this information in the 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 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: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; 
and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to 
specify treatment options. 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 90.2. 
 
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 screening tests are excluded from coverage. You can find this rule at 42 CFR Section
411.15(a)(1) and 42 CFR Section 410.64.

The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.

The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay 50 percent of the Plan-allowed amount in all service settings for out of
network services. Note: All genetic testing requires prior authorization. You can find this information in
Chapter 4 on page 98 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that LT modifier means left side (used to identify procedures performed on the left side of the 
body). RT modifier means right side (used to identify procedures performed on the right side of the 
body) 
 
Modifiers LT and RT apply to codes that identify procedures that can be performed on paired organs, e.g., ears, 
eyes, nostrils, kidneys, lungs, and ovaries. These modifiers should be used whenever a procedure is performed 
on only one side. 
 
Do not report modifiers RT and LT when modifier 50 applies. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.3. 
 
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.
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 PCD coded as E0652, is covered for the treatment of lymphedema extending onto the 
chest, trunk and/or abdomen when all of the following are met: 
 The beneficiary has lymphedema of an extremity as defined above 
 The coverage criteria for an E0650 or E0651 are met 
 The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed 
to improve with a four-week trial. (See below for trial guidelines.) 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. You can find this rule at Local Coverage Determination (LCD) L33829: Pneumatic 
Compression Devices (eff. 10/22/23). 
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 Medicare pays for pulmonary rehabilitation (PR) in a physicians office or a hospital 
outpatient setting. All settings must have the following: 
i. A physician immediately available and accessible for medical consultations and emergencies at all 
times when items and services are being furnished under the program. 
ii. The necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted 
by the medical community as medically necessary (for example, oxygen, cardiopulmonary resuscitation 
equipment, and defibrillator) to treat chronic respiratory disease. 
 
You can find this rule in Medicare Benefit Policy Manual Chapter 15, Section 231. 
 
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 Medicare will consider invasive procedures (only with the techniques outlined in this local 
coverage determination (LCD) and under the conditions described) as reasonable and necessary when 
  
  documentation in the medical record includes a history, physical examination, CEAP clinical classification, and 
a venous duplex scan documenting reflux (>500 msec). 
 
Liquid sclerotherapy will be considered reasonable and necessary to treat telangiectasias, reticular veins, small 
varicose veins (3-6 mm), residual or recurrent veins following endovenous ablation or surgery, and perforator 
veins. Treatment of telangiectasias and reticular veins (C1) (<3 mm) is considered reasonable and necessary 
with documentation of spontaneous and/or traumatic venous hemorrhage, OR for dilated intradermal veins in 
the elderly judged to be a substantial risk for hemorrhage with minimal trauma, OR near an active or healed 
ulcer if judged to contribute to local venous hypertension. 
Saphenous veins (GSV, SSV, AAGSV) management, with UGFS, endovenous thermal ablation 
(radiofrequency or laser), chemical adhesive (cyanoacrylate embolization), MOCA, and surgery (surgical 
ligation and stripping) is considered reasonable and necessary with documentation in the medical record of 
CEAP class C2-C6 disease, reflux (>500 msec), and ANY of the following signs or symptoms: 
Ulceration secondary to venous stasis; 
Significant pain or significant edema associated with saphenous reflux that interferes with activities of daily 
living (ADLs); 
Bleeding associated with ruptured superficial varicosity; 
Recurrent episodes of superficial phlebitis; 
Stasis dermatitis; 
Refractory dependent edema 
Incompetent perforator veins (IPVs) are the most common cause of recurrent varicose veins after treatment. 
Minimally invasive treatments have replaced traditional surgical treatments for IPVs. UGFS and endovenous 
thermal ablation with either radiofrequency or laser energy sources will be considered reasonable and 
necessary9 with the following conditions: 
Demonstrated perforator reflux >500 msec; AND 
No saphenous reflux (greater, small, or accessory) and/or symptomatic varicose tributaries; AND 
An active venous ulcer; AND 
The IPV is at least 3.5 mm in diameter; AND 
The perforator is in the vicinity of the ulcer. 
 
You can find this information in the Local Coverage Determination (LCD) Treatment of Varicose Veins of the 
Lower Extremities L39121. 
 
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 an item is correctly coded when it meets all the coding guidelines. Claims that do not meet
coding guidelines shall be denied as not reasonable and necessary/incorrectly coded. A KX modifier is listed as
required to show requirements specified in the medical policy have been met. You can find this in the Medicare
Local Coverage Determination (LCD) Walkers (L33791).

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.