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 PGx tests are indicated when medications are being considered for use (or already being 
administered) that are medically necessary, appropriate, and approved for use in the patients condition and are 
known to have a gene(s)-drug interaction that has been demonstrated to be clinically actionable as defined by 
the FDA (PGx information required for safe drug administration) or Clinical Pharmacogenetic Implementation 
Consortium (CPIC) guidelines (category A and B). 
The selection of the medications in question must be derived from clinical factors/necessity rather than from a 
PGx test. Once the putative therapeutic agents are selected, and those agents are known to have gene-drug 
interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of 
that test is necessary for the physicians decision-making process regarding safely administering or dosing the 
drug. 
PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular 
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to 
make a preliminary drug selection, PGx testing is not considered reasonable and necessary. You can find this 
rule at Local Coverage Determination (LCD) L38435: MolDX: Pharmacogenomics Testing (eff. 9/29/22). 
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 also say that the decision to use a ventilator or a bi-level positive airway pressure (BiPAP) device is
made based upon the specifics of each person's medical condition. There must be enough detailed information
in the medical record to justify the treatment selected. Ventilators fall under the Frequent and Substantial
Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to
deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device.
This means that products currently classified as Healthcare Common Procedure Coding System (HCPCS) code
E0465, E0466, or E0467 when used to provide continuous positive airway pressure (CPAP) or BiPAP (with or
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS
payment category and will be denied as not reasonable and necessary. You can find this rule in the Local
Coverage Determination (LCD): Respiratory Assist Devices (L33800).

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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
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 enrollees must pay a 20% coinsurance for Medicare-covered benefits for durable medical 
equipment (DME). You can find this information on pages 71 to 72 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 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.

The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724,
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is
covered for beneficiaries whose functional level is 3 or above. The records must document the beneficiary's
current functional capabilities and his/her expected functional potential, including an explanation for the
difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral
amputees often cannot be strictly bound by functional level classifications. You can find this information in
Local Coverage Determination (LCD): Lower Limb Prostheses (L33787).

The rules say that codes L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional
features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in
combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5616, L5810, L5811, L5812,
L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840). The use of additional feature L-codes
may also depend on the assigned K-Level modifier (K0-K4), as referenced in the LCD. You can find this
information in 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 payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
 
1. be provided under an individualized treatment or diagnostic plan; 
 
2. reasonably be expected to improve the patient's condition, or for the purpose of diagnosis; and 
 
3. be supervised and evaluated by a physician.   
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury.  
 
This exclusion extends to claims for services which are provided in inappropriate settings. You can find this 
rule in the Social Security Act, Section 1862(a)(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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules state that all diagnostic X-Ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary and tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, the intent that the test be performed. Contractors shall 
consider order requirements for diagnostic laboratory tests met if there is: 
1. A signed order or signed requisition listing the specific test; or 
2. An unsigned order or unsigned laboratory requisition listing the specific tests to be performed and an 
authenticated medical record that supports the physician/practitioners intent to order the tests; or 
3. An authenticated medical record that supports the physician/practitioners intent to order the specific 
tests. 
 
You can find these rules in Medicare Program Integrity Manual Chapter 6, Section 6.9.1. 
 
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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that definitive urine drug testing (UDT) is reasonable and necessary for the following 
circumstances: 
1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
2. Definitively identify specific drugs in a large family of drugs; 
3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
Meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients 
self- report, presentation, medical history, or current prescribed pain medication plan; 
6. Rule out an error as the cause of an unexpected presumptive UDT result; 
7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; 
and 
8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
You can find this rule in the Local Coverage Determination (LCD) for Controlled Substance Monitoring and 
Drugs of Abuse Testing, L36393. 
 
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 dates of service on or after October 9, 2014, The CologuardTM 
test is covered once every three years for Medicare beneficiaries that meet all of the following 
criteria:
-Age 50 to 85 years, and,
-Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower 
gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal 
immunochemical test (iFOBT)), and,
-At average risk of developing colorectal cancer (no personal history of adenomatous polyps, 
colorectal cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; 
no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or 
hereditary nonpolyposis
colorectal cancer).

You can find this in the National Coverage Determination (NCD): Colorectal Cancer Screening Tests (210.3).

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 Medicare will not pay for dental services. Dental services are items and services involving
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae,
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services,
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.

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 certain dental services as a supplemental (extra) benefit. This
benefit includes only those items and services specifically listed in your Plan contract. LW-overdenturecomplete
mandibular (D5865) and surgical access to an implant body (second stage implant surgery) (D6011)
are not covered under the Plan's dental benefits. Implant body: endosteal implant (D6010) and customfabricated
abutment-includes placement (D6057) are covered at no cost to the enrollee only when exceptional
medical conditions are documented and reviewed for medical necessity. Prior authorization is required.
Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) is
covered but prior authorization is required for procedures performed by a specialist. Medical necessity must be
demonstrated for procedures D7340 - D7997. You can find this information on page 11, 13, 18 and 19 of the
Plan's 2023 dental coverage booklet 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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that a pneumatic compression device (PCD) coded as E0675 is used in the treatment of peripheral 
arterial disease (PAD). A PCD coded as E0675 to treat PAD is not eligible for reimbursement. There is 
insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied as not 
reasonable and necessary. A PCD that provides intermittent limb compression for the purpose of prevention of 
venous thromboembolism is a preventive service. Items that are used for a preventative service or function are 
excluded from coverage under the Medicare DME benefit. You can find this rule in the Local Coverage 
Determination for Pneumatic Compression Devices, L33829. 
 
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 the first position of the Health Insurance Prospective Payment System (HIPPS) code represents a 
combination of the referral source (community or institutional) and the period timing (early or late). A 2 in the 
first position indicates Institutional Early and 4 indicates Institutional Late. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 7, Section 10.1.9. 
 
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 therapeutic 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 has been using a blood glucose monitor (BGM) and performing frequent (four or 
more times a day) testing,
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or 
a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump,
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on 
the basis of BGM or CGM testing results.
5. 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.
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 also say that for PILD claims with procedure code 0275T with dates of service on or after January 9, 
2014, or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors 
shall pay for PILD only when billed with the numeric, 8-digit clinical trial identifier number preceded by the 
two alpha characters CT when placed in Field 19 of paper Form CMS-1500, or when entered without the 
CT prefix in the electronic 837P in Loop 2300 REF02 (REF01=P4). Claims for PILD which are billed 
without an 8-digit clinical trial identifier number shall be returned as unprocessable. You can find this 
information at the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 32, Section 330.1. 
 
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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that if the power wheelchair (PWC) base is not covered, then related accessories will be denied. 
You can find this information in the 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 say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information
(such as copayments, deductibles, and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).

The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.

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 enrollees must pay a 20% coinsurance for Medicare oxygen equipment. You can find this
information on page 71 of the Plan's 2023 Evidence of Coverage (EOC).