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 $40 copayment for outpatient diagnostic tests/in-network/radiation 
therapy. You can find this information on pages 74-76 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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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. The Plan 
contract also says that only manual manipulation of the spine to correct subluxation is covered. Other services 
performed by a chiropractor are not covered. You can find this information on pages 65-66 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 destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) 
nerves will be considered to be medically reasonable and necessary as follows: 
- The paravertebral facet joint(s) have been identified as the source of the patient's pain by undergoing a 
diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the 
pain suggests that the facet joint (s) are the source of the symptoms and appropriate for treatment; and 
- The patient failed conservative treatment. Conservative treatment may include local heat, traction, 
nonsteroidal anti-inflammatory medications and anesthetic and  
- The paravertebral facet joint(s) destruction is performed by appropriately trained providers.  
If pain recurs in the same distribution and nature, the procedure may be provided at the same anatomic site 
(side and spinal level) 6 months from prior treatment.  
You can find this rule in the Local Coverage Determination (LCD): Destruction of Paravertebral Facet Joint 
Nerve(s) (L33814) effective November 28, 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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. The health 
plan contract says that the plan only covers manual manipulation of the spine to correct subluxation. You can 
find this information on page 4-11 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 state that the evidence of clinical utility to support the use of the GeneSight assay is limited to 
patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe 
depression (based upon DSM-V criteria) after at least one prior neuropsychiatric medication failure when 
ordered by a licensed psychiatrist or neuropsychiatrist contemplating an alteration in neuropsychiatric 
medication.  Claims submitted by non-physician providers (NPPs) and physician extenders as ?incident to? 
services will be denied.  The GeneSight assay is limited to once in a life-time. 
 
The rules also say that Documentation supporting the medical need for these tests, including substantiating 
documentation for the ICD-010 code(s) submitted, must be maintained in the patient's medical record. In order 
to be considered medically necessary, the patient must have failed or currently be failing on at least one 
neuropsychiatric medication, and the healthcare provider must be contemplating an alteration in 
neuropsychiatric medication treatment. Prior medication failure and intent to alter medication course consistent 
with the test results must be documented in the patient?s medical record and noted with the test requisition.  
 
You can find these rules in the Local Coverage Determination (LCD) for MolDX: GeneSight' Assay for 
Refractory Depression, L36799. This LCD is effective for services provided on or after November 1, 2019 and 
before July 25, 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 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 Part B prescription drugs. You can find 
this information on pages 79-80 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 $20 copay for x-rays. You can find this information on page 92 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 $45 copayment for specialist visits. You can find this information in 
Chapter 4 on page 93 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 an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis 
of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both 
Alzheimer's disease (AD) and fronto-temporal dementia (FTD). These patients have been evaluated for 
specific alternate neurodegenerative diseases or other causative factors, but the cause of the clinical symptoms 
remains uncertain. You can find this information in the National Coverage Determination (NCD) for FDG PET 
for Dementia and Neurodegenerative Diseases (220.6.13). 
 
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 must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules say that as Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by 
MolDX, and it is a test not currently satisfactorily described by any existing CPT' code. Therefore, to report a 
CGP service, test providers should use CPT' code 81479 at this time, in addition to the approved DEX Z-
CodeTM for the test. Coverage of CGP is limited to one test per surgical specimen and precludes the use of any 
other molecular testing on that specimen. You can find this rule in Local Coverage Article: Billing and Coding: 
MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer 
(A55624) - December 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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g. rest, bracing).  
&#61623; Both PVP and PVA will be considered reasonable and necessary when ALL of the following 
criteria are met: 
o Acute (less than 6 wks) or subacute (6-12 wks)18,28,42 osteoporotic VCF (T5 ? L5) 
confirmed by recent (within 30 days) advanced imaging demonstrating bone marrow 
edema on MRI or bone-scan/SPECT/CT uptake 1-3,8,26,43 and 
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score greater than or equal to 8)4-7 or is 
non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) 
despite optimal non-surgical management (NSM)8 with one of the following:  
&#61607; Worsening Pain or 
&#61607; Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or 
more of the following are present:  
o Progression of vertebral body height loss 
o Greater than 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17) 
Continuum of care 
All patients presenting with vertebral compression fractures (VCF) should be referred for evaluation of 
bone mineral density and osteoporosis education for subsequent treatment as indicated and instructed to 
take part in an osteoporosis prevention/treatment program.8 
2. Malignant Vertebral Fractures 
Osteolytic vertebral metastasis or myeloma with severe back pain related to a destruction of the 
vertebral body, not involving the major part of the cortical bone. 
You can find this rule in the Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L35130) effective July 12, 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 providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules say that claims for A9279 (MONITORING FEATURE/DEVICE, STAND-ALONE OR 
INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, COMPONENTS AND ELECTRONICS, 
NOT OTHERWISE CLASSIFIED) are denied as statutorily non-covered (No Medicare benefit). You can find 
this rule in Local Coverage Article: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive 
Sleep Apnea - Policy Article (A52467) - Effective April 3, 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 state that only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is 
statutorily non-covered. You can find this information in the Local Coverage Article: Oxygen and Oxygen 
Equipment - Policy Article (A52514). 
 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 health 
plan contract says that eye refractions are covered during a routine exam. You can find this information on page 83 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 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 $250 copayment for Outpatient surgery provided in an ambulatory 
surgical center. You can find this information on page 75 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 state that Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave 
technologies) is covered when: 
 
    - Only when dual MBBs provide = 80% relief of the primary or index pain and duration of relief is 
consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be 
considered.  
    - Repeat denervation procedures involving the same joint will only be considered medically necessary if the 
patient experienced = 50% improvement of pain and improvement in patient specific Activities of Daily Living 
(ADLs) documented for at least 6 months. 
 
You can find this information in the Local Coverage Determination (LCD):  Facet Joint Injections, Medial 
Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35996). 
 
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 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 pages 28-32 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 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 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, as a member of our plan, you can receive your care from either a network provider or an out-
of-network provider. If you use an out-of-network provider, your share of the costs for covered services may be 
higher. Referrals from your PCP are not required for emergency care or urgently needed services. You can find 
this information on page 44 of the Plan's 2020 Evidence of Coverage.