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 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 up to a copay maximum of $250 for Outpatient diagnostic tests. You can find this information on page 80 of the Plan's 2020 Evidence of Coverage (EOC).

The Plan contract says that enrollees must pay a $315 copayment for Outpatient surgery. You can find this information on page 86 of the Plan's 2020 Evidence of Coverage.

The Plan contract says that enrollees must pay a $50 copayment for Physician specialist services. You can find this information on page 87 of the Plan's 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the following revenue codes when billed under OPPS without HCPCS codes are packaged
services for which no separate payment is made. However, the cost of these services is included in the
transitional outpatient payment (TOP) and outlier calculations. The revenue codes for packaged services are:
0250, 0251, 0252, 0254, 0255, 0257, 0258, 0259, 0260, 0262, 0263, 0264, 0269, 0270, 0271, 0272, 0275, 0276,
0278, 0279, 0280, 0289, 0370, 0371, 0372, 0379, 0390, 0399, 0560, 0569, 0621, 0622, 0624, 0630, 0631, 0632,
0633, 0637, 0681, 0682, 0683, 0684, 0689, 0700, 0709, 0710, 0719, 0720, 0721, 0762, 0810, 0819, and 0942.
You can find this rule in the Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual
Chapter 4, Section 20.5.1.1.
The rules say that under the OPPS, packaged services are items and services that are considered to be an
integral part of another service that is paid under the OPPS. No separate payment is made for packaged services
because the cost of these items and services is included in the APC payment for the service of which they are
an integral part. For example, routine supplies, anesthesia, recovery room use, and most drugs are considered to
be an integral part of a surgical procedure so payment for these items is packaged into the APC payment for the
surgical procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare Claims
Processing Manual, Chapter 4, Section 10.4.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules 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, 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 some preventative and comprehensive services that may require prior authorization or be subject to limitations or exclusions. You can find this information on pages 66-68 of the Plan's 2021 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, 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 contract lists the dental services that are covered. Periapical x-ray is not listed and therefore is not a covered service. Unspecified preventive service is not listed and therefore is not a covered service either. You can find this information on pages 87 and 88 of the Plan's 2020 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.
Medicare may cover the use of a Food & Drug Administration (FDA)-approved drug or biological if it is safe and effective and otherwise reasonable and necessary for the patient. FDA approved drugs used for indications
other than what is indicated on the official label may be covered if the use is determined to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.
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 state that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of service. You can find this information in the Medicare Claims Processing Manual, Chapter 26, Section 10.6.

The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You can find this information in the MLN Matters article number MM7631, "Revised and Clarified Place of Service (POS) Coding Instructions."

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 Genomic Sequential Analysis Panel will be considered reasonable and necessary in the evaluation of blood or bone marrow samples for patients with acute myelogenous leukemia (AML) in certain circumstances. There are certain genetic biomarkers which are considered reasonable and necessary for testing in these patients. The coverage rules provide a list of 17 biomarkers which meet this criterion. The billing and coding guidelines indicate that the covered code for use with this testing is 81450 which is defined as targeted genomic sequencing with analysis for 5-50 genes. You can find this information in the Local Coverage Determination (LCD): Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases (L37606) and the related Local Coverage Article: Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases (A56793).

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 proper coding is necessary on Medicare claims because the codes are generally used to determine coverage and payment amounts. CMS accepts only HIPPA approved ICD-9-CM or ICD-10-CM/ICD-10-PCS codes, depending on the date of service. Use the diagnosis code that describes the patient's diagnosis, symptom, complaint, condition or problem. Assign the code to the highest level of specificity. The "highest degree of specificity" refers to assigning the most precise code that most fully explains the narrative description of the symptom or diagnosis. You can find these rules in the Medicare Claims Processing Manual Chapter 23, Sections 10. The rules say certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere." Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. "In diseases classified elsewhere" codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code, and they must be listed following the underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention. You can find this rule in the ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 (October 1, 2019 - September 30, 2020).
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, 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. These services are listed in the Plan's Office Manager Reference Manual (ORM). You can find this information on pages 66-68 of the Plan's 2021 Evidence of Coverage (EOC) and the ORM.
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 ConfirmMDx is covered under the following conditions: 1. Males aged 40 to 85 years' old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors, and 2. The previous negative prostate biopsy must have collected a minimum of 8 tissue cores (but not have received a saturation biopsy of greater than 24 tissue cores) and remaining FFPE tissue from all cores is available for testing, and 3. Minimum tissue volume criteria of 20 microns of prostate biopsy core tissue is available (40 microns preferable), and 4. Previous biopsy histology does not include a prior diagnosis of prostate cancer or cellular atypia suspicious for cancer (but may include the presence of high-grade prostatic intraepithelial neoplasia (HGPIN), proliferative inflammatory atrophy (PIA), or glandular inflammation), and 5. Patient is not being managed by active surveillance for low stage prostate cancer, and 6. Tissue was extracted using standard patterned biopsy core extraction (and not transurethral resection of the prostate (TURP), and 7. Patient has not been previously tested by ConfirmMDx from the same biopsy samples or similar molecular test. You can find this rule in the Local Coverage Determination (LCD): MoIDX: ConfirmMDx Epigenetic Molecular Assay (L37005) effective November 1, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that facet joint interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria:

-Duration of pain of at least three (3) months 
-Pain is intermittent or continuous with average pain levels of 6 or greater on a visual-numerical analogue pain scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability 
-Documented failure to respond to conservative care such as nonsteroidal anti-inflammatory drugs (NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated) 
-History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication 
-Physical examination with documented signs that the facet joint is the primary suspected source of pain 
-There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity

You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892) - Effective November 21, 2019.

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 Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract 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 47 of the plan's 2021 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 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 $200 copayment for each Medicare-covered diagnostic radiology and complex imaging service. You can find this information on page 19 of the Plan's 2020 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 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 $200 copayment for Medicare-covered diagnostic radiology services
provided in an outpatient hospital setting. You can find this information on page 78 of the Plan's 2020 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 indications for facet joint injections are:

-At least 3 months of moderate to severe pain with functional impairment inadequately responsive to
conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated).
-Predominant axial pain that is not associated with radiculopathy or neurogenic claudication.
-Absence of non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor,
infection, or significant deformity.
-Clinical assessment that implicates the facet joint as the putative source of pain.

You can find this rule in Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks,
and Facet Joint Radiofrequency Neurotomy (L34832) - Effective November 1, 2019.

The rules say that if, after the first medial branch block injection, the patient experiences 80% or more relief of
their primary (index) pain, lasting a time period consistent with the local anesthetic used, the patient may
undergo a second, confirmatory medial branch block. You can find this rule in Local Coverage Determination
(LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34832) -
Effective November 1, 2019.

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 international consensus documents previously recommended 0.5 seconds as a cutoff value for all veins to use for lower limb venous incompetence.10 Cutoff values of both 350 milliseconds and 500 milliseconds have been suggested for the perforating veins. 500 milliseconds is recommended as the cutoff value for saphenous, tibial, deep femoral, and perforating vein incompetence, and 1 second for femoral and popliteal vein incompetence.

You can find this information in the Local Coverage Determination (LCD): Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.