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 20% coinsurance for Medicare Part B prescription drugs. You can find this information in Chapter 4 on page 84 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, 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 1
periapical x-ray per calendar year. You can find this information on page 86 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 does not pay for hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).
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 costs associated with loss and damage warranty claims are not covered by the Plan. You can find this information on page 72 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 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 include a list of appropriate diagnosis codes for CPT codes 95870 and 95938. The rules say that diagnosis codes that do not support medical necessity are all those not listed under the "ICD-10 Codes that Support Medical Necessity" section of this article. You can find this information in Local Coverage Article A54095: Billing and Coding: Nerve Conduction Studies and Electromyography and Local Coverage Article A56773: Billing and Coding: Neurophysiology Evoked Potentials (NEPs).
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 effective for services performed on or after March 16, 2018, the Centers for Medicare &
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following
requirements are met:

a. Patient has:
- either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and
- not been previously tested with the same test using NGS for the same cancer genetic content,
and
- decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
b. The diagnostic laboratory test using NGS must have:
- Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic;
and,
- an FDA-approved or -cleared indication for use in that patient's cancer; and,
- results provided to the treating physician for management of the patient using a report template
to specify treatment options.

Effective for services performed on or after March 16, 2018, NGS as a diagnostic laboratory test for patients
with acquired (somatic) cancer are non-covered if the cancer patient does not meet the criteria noted above.

You can find these rules in National Coverage Determination (NCD) Next-Generation Sequencing (90.2).

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 plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 10 and 11 of the 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 a supplier of a covered item of durable medical equipment (DME) may not contact an
individual by telephone regarding the furnishing of a covered item to the individual unless: the individual has
given written permission to the supplier to make contact by telephone regarding the furnishing of a covered
item; or, the supplier has furnished a covered item to the individual and the supplier is contacting the individual
only regarding the furnishing of such covered item, or another covered item to this same individual within 15
months. If a supplier knowingly contacts an individual in violation of this prohibition, no payment may be
made for any item subsequently furnished to the individual by the supplier. You can find this information in the
Social Security Act, Section 1834(a)(17).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the diagnostic procedures should be performed with the intent that if successful, a RFA
procedure would be considered the primary treatment goal at the diagnosed level(s).
A second diagnostic facet procedure is considered medically reasonable and necessary to confirm validity of
the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure
may only be performed a minimum of 2 weeks after the initial diagnostic procedure.
1. An initial diagnostic facet joint procedure will be considered medically reasonable and
necessary when the patient meets the criteria outlined under the indications for facet joint
interventions.
2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and
necessary in patients who meet BOTH of the following criteria:
- The patient meets the criteria for the first diagnostic procedure; AND
- After the first diagnostic facet joint procedure, there must be a consistent positive
response of at least 80% relief of primary (index) pain (with the duration of relief being
consistent with the agent used).
You can find this rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management,
L34892 (eff 04/25/21).
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.
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.
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 40 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 $0 copayment for allergy testing, and a $100 copayment for all other diagnostic tests. You can find this information in Chapter 4 on page 81 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 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 specific
services and procedure codes that are listed in the Plan's contract. Services and codes not listed are not covered.
You can find this information on pages 102-108 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 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 you should receive your care from a network provider (for more information about this, see Section 2 in this chapter). Our plan does offer a Point of Service (POS) option for certain services. Most services obtained from out-of-network providers require prior authorization and are subject to a $500 deductible and fifty percent (50%) coinsurance. The maximum plan benefit for out-of-network covered services is $5,000. Once the plan has paid $5,000 for benefits, you will pay 100% of all out-of-network services for the rest of the calendar year. If you receive care from an out-of-network provider (a provider who is not part of our plan's network), such services will not be covered unless you obtain a prior authorization. Here are two exceptions: The plan covers emergency care or urgently needed services that you get from an out-of-network provider. The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area. You can find this information on page 43 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 a seat lift mechanism is covered if all of the following are met:
1. The enrollee must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
2. The seat lift mechanism must be a part of the treating practitioner's course of treatment and be prescribed to improve, or stop deterioration of, the enrollee's condition.
3. The enrollee must be completely unable to stand up from a regular armchair or any chair in the home.
4. Once standing, the enrollee must have the ability to walk.
You can find this information in the Local Coverage Determination (LCD): Seat Lift Mechanisms (L33801).
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 for patients whose weight loss is the result of bariatric surgery, abdominal lipectomy/panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent six months. You can find this rule at Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L35090).
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 pay for an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.
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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 medically accepted off-label uses for Food and Drug Administration (FDA) approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of compendia which define if a use is medically accepted. The off-label use must be supported in one or more of these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state to be reasonable and necessary. You can find these rules and the list of the Medicare-recognized compendia in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.5.

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 state 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 > 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 these rules in Local Coverage Determination (LCD) MolDX: ConfirmMDx Epigenetic Molecular Assay (L36327). 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.