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 screening tests are excluded from coverage. The only exceptions are for the following services: 1. screening mammography, 2. colorectal cancer screening tests, 3. screening pelvic exams, 4. prostate cancer screening tests, 5. glaucoma screening exams, 6. ultrasound screening for abdominal aortic aneurysms (AAA), 7. cardiovascular disease screening tests, 8. diabetes screening tests, and 9. screening electrocardiograms, and 10. certain other testing recommended by the United States Preventive Services Task Force and approved by the Centers for Medicare and Medicaid Service. You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.
The rules say that routine screening and prophylactic testing for lipid disorders are not covered by Medicare. While lipid screening may be medically appropriate, Medicare by statue does not pay for it. Lipid testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk factors such as family history, tobacco use, etc. Coverage is denied for all non-lipid biomarkers when used for CV risk assessment including but not limited to, biochemical, immunologic, and hematologic, and genetic biomarkers for CV risk assessment regardless of whether ordered in a panel or individually. You can find this rule in the Local Coverage Determination for Molecular Diagnostics Service Program (MolDX): Biomarkers in Cardiovascular Risk Assessment, L36358 (eff 10/01/19).
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 effective June 8, 2012, the Centers for Medicare & Medicaid Services (CMS) will allow
coverage for Transcutaneous Electrical Nerve Stimulation (TENS) for CLBP only when the beneficiary is
enrolled in an approved clinical study meeting specific criteria. You can find this rule in the Centers for
Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National
Coverage Determinations (NCD) Manual, Section 160.27.
The rules say that a PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in
beneficiaries with chronic and severe lymphedema when all of the following three requirements are met:
1. The beneficiary has a diagnosis of lymphedema as defined above, and
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented
presence of at least one of the following clinical findings:
a. Marked hyperkeratosis with hyperplasia and hyperpigmentation,
b. Papillomatosis cutis lymphostatica,
c. Deformity of elephantiasis,
d. Skin breakdown with persisting lymphorrhea,
e. Detailed measurements over time confirming the persistence of the lymphedema with a history
evidencing a likely etiology, and
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to
other clinical treatment over the course of a required four-week trial.
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. You can find this rule at
Local Coverage Determination (LCD) L33829: Pneumatic Compression Devices (eff. 1/1/20).
The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using
a compounded drug, not otherwise classified (NOC) code. You can find this information in the
Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 20.1.2.
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 providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).
The rules state that 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 in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 26, Section 10.6.
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 Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays
for reasonable and necessary items and services used to diagnose and treat complications arising from
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they
are not available through in-network providers. Medicare plans may require reporting when enrollees
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National
Coverage Determinations Manual, Chapter 1, Section 310.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that 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 core
buildup when x-rays show that it is medically necessary. You can find this information on page 61 of the Plan's
2021 Evidence of Coverage (EOC) and in the Plan's Dental Vendor's 2021 Office Reference Manual.
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 generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:
1. blood-clotting factors;
2. drugs used in immunosuppressive therapy;
3. erythropoietin for dialysis patients;
4. osteoporosis drugs for certain homebound patients;
5. certain oral cancer drugs;
6. oral anti-emetics used in certain situations;
7. drugs treated as supplies during an outpatient hospital procedure; and
8. drugs required for the effective use of durable medical equipment.

Oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. 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 $225 copayment for in-network advanced imaging services, not including x-rays. If advanced imaging services are received as part of an emergency department evaluation then you will only pay the advanced imaging copayment, not the emergency room copayment. You can find this information on page 83 and 105 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 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).
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 there is a a 20% coinsurance for out-of-network diabetic monitoring supplies after the
$75 deductible is met which applies to certain items and services. The Plan deductible applies to the diabetic
supplies. You can find this information on pages 55 to 56 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 lumbar epidural injections are generally performed to treat pain arising from spinal nerve
roots. These procedures may be performed via three distinct techniques, each of which involves introducing a
needle into the epidural space by a different route of entry. These are termed the interlaminar, caudal, and
transforaminal approaches. The procedures involve the injection of a solution containing local anesthetic with
or without corticosteroids. The indications are:
1. Pain associated with
a. Herpes zoster and/or
b. Suspected radicular pain, based on radiation of pain along the dermatome (sensory distribution) of a nerve
and/or
c. Neurogenic claudication and/or
d. Low back pain, National Pain Rating Scale (NPRS) 3/10 or more (moderate to severe pain) associated with
significant impairment of activities of daily living (ADLs) and one of the following:
-substantial imaging abnormalities such as a central disc herniation,
-severe degenerative disc disease or central spinal stenosis
2. Failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which includes
appropriate oral medication(s) and physical therapy to the extent tolerated. Exceptions to the four week wait
may include:
a. pain from Herpes Zoster
b. at least moderate pain with significant functional loss at work or home
c. severe pain unresponsive to outpatient medical management
d. inability to tolerate non-surgical, non-injection care due to coexisting medical condition(s)
e. prior successful injections for same specific condition with relief of at least three months' duration.
You can find this rule in the Local Coverage Determination (LCD) - Lumbar Epidural Injections (L35937) -
Effective October 1, 2021.
The rules say that for epidural injections, there must be an appropriately comprehensive evaluation of all
potential contributing pain generators and treatment in accordance with an established and documented
treatment plan. You can find this rule in Local Coverage Determination (LCD): Lumbar Epidural Injections
(L35937) - Effective October 17, 2019.
The rules say that when a diagnostic spinal nerve block is performed, post-block assessment of percentage pain
relief must be documented. Response to each epidural should be determined prior to determining the value of a
repeat epidural and the specific methods used for subsequent epidurals. You can find this rule in Local
Coverage Determination (LCD): Lumbar Epidural Injections (L35937) - Effective October 17, 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 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 Plan contract also says that dental services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. There is no other dental coverage. You can find this information on pages 40 to 41 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 $90 copayment for emergency room services. You can find this information in Chapter 4 on pages 65 to 66 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 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.
The rules say that the Annual Wellness Visit will include the establishment of, or update to, the individual's medical and family history, measurement of his or her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and fostering the coordination of the screening and preventive services that may already be covered and paid for under Medicare Part B. This is seen in the CMS MLN Matters article number MM7079 (effective January 1, 2011).
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 $10 copayment for physician visits. You can see this on page 87 of the Plans 2021 Evidence of Coverage.
The Plan contract says that the wellness visit alone is no charge. Certain services rendered during a wellness visit may take a copayment/ coinsurance. When services other than preventive are performed, the cost share (copayment/ coinsurance) associated with the other service will apply. You can see this on page 54 of the Plans 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 that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).

The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one unit of service. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Manual, Chapter X(F).

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. If an independent lab bills for services, the place where the sample was taken is reported as the POS. An independent laboratory taking a sample in its laboratory shows "81" as place of service. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04Medicare Claims Processing Manual Chapter 26, Section10.6.

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 pages 46-57 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 $250 per day for other outpatient procedures and services, including, but
not limited to, diagnostic and therapeutic endoscopy for outpatient surgery, including services provided at
hospital outpatient facilities and ambulatory surgical centers. You can find this information on pages 101 to
102 of the Plan's 2021 Evidence of Coverage (EOC).