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 an event monitor, or event recorder, is a patient-activated or event-activated 
electrocardiographic (EKG) device that intermittently records cardiac arrhythmic events as they occur. The 
recording is captured either on a magnetic tape or other digital medium. Upon detecting symptoms, the wearer 
presses a button, which activates the recorder to save (i.e., memorize) an interval of pre-symptom EKG data 
along with data during and subsequent to the symptomatic event. Self-sensing recorders (also known as event-
activated or automatic trigger) do not require patient input to capture these data. Single or multiple events may 
be recorded. The device is worn at all times, usually for up to 30 days. These are considered memory loop 
recorders (MLR). 
 
Another type of pre-symptom loop recorder is implanted subcutaneously in a patients upper left chest and may 
remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related but is too 
infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
Covered uses are to: 
a. Detect, characterize, and document symptomatic transient arrhythmias; 
b. Initiate, revise, or discontinue arrhythmic drug therapy; or,  
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only 
if 24-hour coverage is provided). You can find this information in the Centers for Medicare & Medicaid 
Services, Internet-Only Manual, Publication Number 100-03, Medicare National Coverage Determinations 
(NCD) Manual, Section 20.15. 
 
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 specific dental items/services stated in the Plans contract. You can find this information on pages 
71-75 of the Plans 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 Medicare Part B does not pay for drugs that are usually self-administered. Medicare Part B
also covers immunosuppressive drugs (transplant drugs) if Medicare paid for the transplant. You must have
Part A at the time of the covered transplant. You can find this rule in the Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50,
50.2, 50.5, and 110.3.

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 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 $175 copayment for each Medicare-covered radiological diagnostic
services, not including x-rays. You can find this information on page 80 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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual
for Medicare Services, Chapter I(A).

Hospital Inpatient or Observation Discharge Day Management Services, CPT code 99238 or 99239 is a faceto-
face evaluation and management (E/M) service between the attending physician and the patient. The E/M
discharge day management visit shall be reported for the date of the actual visit by the physician or qualified
nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only
one hospital inpatient or observation discharge day management service is payable per patient per hospital stay.
You can find this rule in the Centers for Medicare and Medicaid Services Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners, Section 30.6.9.2, B.

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 is insulin-treated with multiple (three or more) daily administrations of 
insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump,
3. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on 
the basis of blood glucose monitor (BGM) or CGM testing results,
4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person 
visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-3) 
above are met; and,
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 the applicable payments made under the prospective payment systems are payment in full for
all facility or hospital services, as defined in 42 CFR Section 409.10. CMS does not pay any provider or
supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must
furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42
CFR Section (409.3). You can see this in 42 CFR Section 412.50 - "Furnishing of inpatient hospital services
directly or under arrangements."

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 a Medicare plan may not pay for services given by a physician or other practitioner who has
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed
Care Manual, Chapter 6, Section 60.2.

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 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 Guidance Manual, Section 50.12.1. 
 
The rules also say that claims lines billed with codes E0148 and E0149 without a KX, GA, GY or GZ modifier 
will be rejected as missing information. You can find this rule in the Local Coverage Article (LCA) for 
Walkers - Policy Article (A52503). 
 
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 $95 copayment per visit for emergency services. You can find this 
information on page 58 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 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 skin replacement surgery is considered an advanced treatment modality (not a conservative 
wound care measure). Pre-service record specifically addresses circumstances as to why the wound has failed 
to respond to standard wound care treatment of greater than 4 weeks and must reference specific interventions 
that have failed based on the prior wound evaluation. Such record should include updated medication history, 
review of pertinent medical problems that may have arisen since the previous wound evaluation, and 
explanation of the planned skin replacement surgery with choice of skin substitute graft product. The procedure 
risks and complications should also be reviewed and documented. You can find this information in the Local 
Coverage Determination (LCD): Application of Skin Substitute Grafts for Treatment of DFU and VLU of 
Lower Extremities (L36377). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
    
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 84-85 of the Plans 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 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. The Plan contract does not
list limited oral evaluation or cone beam CT capture as covered benefits. You can find this information on page
49 of the 2023 Evidence of Coverage (EOC).

The Plan contract says that there is an optional supplemental dental plan that you can purchase for $35 per
month. You can find this information on pages 74-76 of the 2023 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 under Telehealth Provided in Patient's Home (January 1, 2022), the location where health
services and health related services are provided or received, through telecommunication technology. Patient is
in their home (which is a location other than a hospital or other facility where the patient receives care in a
private residence) when receiving health services or health related services through telecommunication
technology. Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA. You can
find this in the Centers for Medicare & Medicaid Claims Processing Manual Chapter 26 - Completing and
Processing Form CMS-1500 Data Set.

The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can
find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.

The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid
information for all these elements may be returned as un-processable. You can find this rule in the Medicare
Claims Processing Manual, Chapter 1, Section 80.3.1.

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 state that the following must be present for coverage eligibility: 
 
For tests that are specifically indicated in patients whom are known to have a myeloid malignancy at the time 
  
  of testing, NCD 90.2 applies. 
The patient has a diagnosis of AML, MDS, or MPN. AML, MDS, and MPN are herein classified as refractory 
and/or metastatic cancers and fulfil the NCD 90.2 criteria. 
The test has satisfactorily completed a TA by MolDX for the stated indications of the test. 
The assay performed includes at least the minimum genes and positions indicated for its intended use, as 
described in an associated coverage Article or found in the TA forms. 
For patients that do not have a diagnosis of a myeloid malignancy, where one is suspected, the patient must 
have an undefined cytopenia for greater than 4 months, other possible causes have been reasonably excluded. 
Testing is performed on bone marrow biopsies, bone marrow aspirates, bone marrow clots, peripheral blood 
samples, or extramedullary sites suspected of harboring a myeloid malignancy. 
Situations in which Test should not be used or coverage is denied: 
 
The test in question will be non-covered if: 
 
A TA has not been satisfactorily completed by MolDX. For tests that are currently covered but a TA 
submission has not been made, providers must submit completed TA materials by February 10th, 2020 or 
coverage will be denied. 
Another NGS test was performed on the same surgical specimen/ blood draw (specimen obtained on the same 
date of service). 
Testing falls within scope of NCD 90.2 and has been tested with the same test for the same genetic content. 
 
You can find this information in the Local Coverage Determination (LCD) MolDX: Next-Generation 
Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies L38047. 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.