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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when the patient has a personal history of melanoma and either:  
 
1. Has Stage T1b and above OR Has T1a with documented concern about adequacy of microstaging, AND 
2. Does not have metastatic disease AND  
3. Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other 
information is greater than 5% AND  
4. Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended use of 
the test.  
 
This criteria can be found in Local Coverage Determination (LCD): MolDX: Melanoma Risk Stratification 
Molecular Testing (L37748). 
 
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 items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for the requested items or services, but only when they are received from an in-network provider. You 
can find this information in Chapter 4 on pages 60-62 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 the Centers for Medicare & Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter I(V). 
 
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 Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17). 
 
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 $25 copayment for each in-network Medicare-covered visit for physical, 
speech or occupational therapy visit.  You can find this information on page(s) 77 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 Covered Indications: 
 
Wireless Capsule Endoscopy (WCE) is indicated for the diagnosis of occult gastrointestinal bleeding (i.e., 
likely involving the small intestine), the site of which has not previously been identified by any of the 
following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological 
procedures. 
WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy and these tests 
have failed to reveal a source of bleeding. Medicare would not expect to see a WCE provided if upper and 
lower endoscopy has not previously been performed. Documentation in the medical record must indicate that 
the beneficiary has suspected GI blood loss with or without anemia. Appropriate differential diagnoses for the 
evaluation of such bleeding include: 
Angiodysplasia 
Neoplasm 
Iron deficiency anemia, which is unexplained after upper and lower endoscopy 
Zollinger-Ellison syndrome 
Tuberculosis 
Vasculitis 
Radiation enteritis 
Meckels diverticulum 
Jejunal diverticula 
Chronic mesenteric ischemia 
Other indications include the management of celiac disease (e.g., surveillance for small-intestinal cancer) and 
of Crohns disease (that is, either Crohns disease is suspected, but not diagnosed, or colonic involvement of 
Crohns disease is known, but it is necessary to determine whether there is also involvement of the small 
bowel). In addition, WCE is indicated where an indeterminate type of colitis exists, but where a more specific 
diagnosis is being sought via small bowel evaluation. 
Esophageal capsule endoscopy may be used in the evaluation of esophageal varices in patients with portal 
hypertension, as an alternative to upper GI endoscopy. You can find this information in the Local Coverage Determination (LCD): Wireless Capsule Endoscopy 
(L35089). 
 
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 also say that an expandable controller is capable of accommodating one or more of the following 
additional functions: 
a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) 
other than a standard proportional joystick. 
b. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
c. Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators 
though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
d. A separate display (i.e., for alternate control devices) 
e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs 
drive control) 
f. An attendant control 
require the use of an additional component, E2310 or E2311.) 
An expandable controller may also be able to operate one or more of the following: 
A separate display (i.e., for alternate control devices) 
Other electronic devices (e.g., control of an augmentative speech device or 
computer through the chair's drive control) 
An attendant control 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. 
 
You can find these rules in Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
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 treatment for LUTS/BPH treatment will be considered medically reasonable and necessary 
when performed ONCE in patients with the following: 
 
Indications including ALL of the following: 
Age greater than or equal to 80 
Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
Persistent moderate to severe symptoms despite maximal medical management 
including ALL of the following: 
 
International Prostate Symptom Score (IPSS) greater than or equal to 124 
Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s4 (voided volume greater than 125 cc) 
Failure, contraindication or intolerance to at least three months of conventional medical therapy for LUTS/BPH 
(e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
Only treatment using an FDA approved/cleared device will be considered medically reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Transurethral Waterjet Ablation of 
the Prostate (L38712). 
 
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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 
- The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
- Other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been 
tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient; 
- Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
- All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient must be available; and 
- Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this information in the Centers for Medicare & Medicaid Services, Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 160.7. 
 
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 pharmacogenetics testing will be considered medically reasonable and necessary if: 
1. The patient has a condition where clinical evaluation has determined the need for a medication that has 
a known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
2. The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-
reviewed process and determined to demonstrate actionability in clinical decision making; or is listed in the 
Food and Drug Administration (FDA) table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label. 
You can find this information in the Local Coverage Determination (LCD): Pharmacogenomics Testing 
(L39073). 
 
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) 7 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 state that code 0037U is only covered when billed with a covered diagnosis code. Any diagnosis not 
listed is not covered. You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 90.2, 
Transmittal Number 10346. 
 
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) 30-31 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 state that suppliers must add a KX modifier to the Ankle-Foot Orthosis (AFO)/Knee-Ankle-Foot 
Orthosis (KAFO) base and addition codes only if all of the coverage criteria in the related Local Coverage 
Determination (LCD) have been met and evidence of such is retained in the suppliers files and available to the 
Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) upon request. 
 
If all of the criteria in the related LCD have not been met, the GA or GZ modifier must be added to the code. 
When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim 
line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they 
have not obtained a valid ABN. 
 
Claim lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information. You 
can find this information in the Local Coverage Article: Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article 
(A52457). 
 
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 in the case of tests for infectious agents, methodologies include detection by 
immunofluorescence, immunoassay, or nucleic acid probe techniques. A single laboratory procedure shall be 
reported as one unit of service whether it generates one or multiple results. When multiple procedures, multiple 
methodologies, or multiple kits are medically necessary and used to perform a test for multiple infectious 
agents, the units of service reported for codes that identify multiple infectious agents equals the number of 
different procedures, methodologies, or kits used to perform the test. You can find this information in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) 
Manual, Chapter 10, Section M(15). 
 
The rules say that gastrointestinal (GI) panels will only be covered when targeted testing is not appropriate 
AND according to the following additional criteria: 
 For immune-competent patients, at least 1 of the following must apply: 
 Testing is ordered by a clinician specialist in Infectious Diseases or Gastroenterology for a 
patient with severe and established underlying GI pathology (i.e., inflammatory bowel disease 
(IBD), paralytic ileus, radiation therapy to the intestine) AND identification of an infectious 
cause is necessary to determine next steps in patient management. 
 The patient is seriously or critically ill or at imminent risk of becoming seriously or critically 
ill (as defined by the American Hospital Associations General Guide for the Release of 
Information on the Condition of Patients)
3
 as a result of a presumed GI infection AND the 
patient is being treated in an appropriate critical care facility. 
 The patients clinical indication for GI panel testing is diarrhea, and ALL of the following 
apply:  The diarrheal illness MUST be acute or persistent with signs or risk factors for severe 
disease (i.e., fever, bloody diarrhea, dysentery, dehydration, severe abdominal pain) that 
may warrant hospitalization AND/OR 
 The diarrheal illness is not resolving after 7 days AND the patient has NOT taken 
laxatives within 24 hours of the test. 
 
You can find this rule in the Local Coverage Determination for Molecular Diagnostics (MolDX): Molecular 
Syndromic Panels for Infectious Disease Pathogen Identification Testing, L39003.  
 
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.