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 state that effective for services performed on or after January 27, 2020, MACs may determine 
coverage of NGS as a diagnostic laboratory test for patients with germline (inherited) cancer only when the test 
is performed in a CLIA-certified laboratory, when ordered by a treating physician, when results are provided to 
the treating physician for management of the patient and when the patient has: 
 
    any cancer diagnosis; and, 
    a clinical indication for germline (inherited) testing of hereditary cancers; and, 
    a risk factor for germline (inherited) cancer; and, 
    not been previously tested with the same germline test using NGS for the same germline genetic content. 
 
You can find this information in the National Coverage Determination (NCD) Next Generation Sequencing 
(NGS) 90.2. 
 
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 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 the most you will have to pay out-of-pocket for in-network medical services that are covered 
under Medicare Part A and Part B is $5,150. You can find this information on page 46 of the Plans Evidence 
of Coverage (EOC). 
 
The Plan contract says that enrollees must pay $0 copayment for days 1 to 20 and a $196 copayment per day 
for days 21 to 100 for SNF care. You can find this information on page 88 of the Plan's 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that non-thermal modalities for facet joint denervation including chemical, low-grade thermal 
energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation are considered not medically 
reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD): Facet Joint 
Interventions for Pain Management (L34892). 
 
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 the most you will pay for out-of-pocket for in-network covered Part A and Part B services in 2023 
is $2,400. You can find this information on pages 38 to 39 of the Plans 2023 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $225 copayment per day for days 1 to 7 for Medicare-
covered hospital care each time you are admitted and $0 copayment for additional days for inpatient hospital 
care. You can find this information on pages 57 to 58 of the Plan's 2023 (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. You can find this information on pages 93-96 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 in Chapter 3 on pages 38-29 of 
the Plan's 2023 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 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 certain services require prior authorization. You can find this information on pages 44 and 73 
of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $0 copayment for days 1 to 20 and a $196 copayment per day for days 21 
to 100 for SNF care. You can find this information on pages 79 to 80 of the Plan's 2023 Evidence of Coverage 
(EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for dental items/services stated in the Plans contract. You can find this information on pages 114-117 
of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The Plan contract says that when a skilled nursing facility (SNF) resident receives a portable x-ray service 
during the course of a  
Medicare-covered stay in the SNF, only the services professional component  
(representing the physicians interpretation of the test results) is a separately billable  
physician service under Part B (see Section 20.1 of this chapter and Section 20.1.1 of Chapter 6). By  
contrast, the technical component representing the procedure itself, including any  
associated transportation and setup costs, would be subject to consolidated billing (the  
SNF bundling requirement for services furnished to the SNFs Part A residents), and  
must be included on the SNFs Part A bill for the residents covered stay (Bill Type 21x)  
rather than being billed separately under Part B. 
 
 
You can find this information in the Medicare Claims Processing Manual, Chapter 13 - Radiology Services and 
Other Diagnostic  
Procedures, Section 90.5 - Transportation of Equipment Billed by a SNF to a MAC. 
 
 
The rules say that procedures and examinations which are not covered under the portable x-ray provision  
include the following:  
 Procedures involving fluoroscopy;  
 Procedures involving the use of contrast media;  
 Procedures requiring the administration of a substance to the patient or injection of a substance into the 
patient and/or special manipulation of the patient;  
 Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of 
osteopathy or which require that medical judgment be exercised;  Procedures requiring special technical competency and/or special equipment or materials; 
 Routine screening procedures; and 
 Procedures which are not of a diagnostic nature.  
 
 
You can find this information in the Medicare Benefit Policy Manual, Chapter 15 (page 110), 80.4.4 - 
Exclusions from Coverage as Portable X-Ray Services. 
 
The rules say that if the mobile unit is serving an entity for which another place of service (POS) code already 
exists, providers should use the POS code for that entity. You can find this information in Medicare Claims 
Processing Manual, Chapter 26, Section 10.5 (Special Considerations for Mobile Unit Settings (Code 15) page 
32 of 77). 
 
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for 
patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the 
underlying conditions and appropriate attempts at medication management, physical therapy, psychological 
therapy and other less invasive interdenominational treatments. As with spinal nerve stimulations (spinal cord 
stimulators (SCS) are dealt with in a companion policy), severe neuropathic pain is typically well suited for 
successful responses to PNS. There may be rare, selected situations where both spinal cord stimulators and 
peripheral neurostimulators are used together. You can find this information in the Local Coverage 
Determination (LCD) L37360: Peripheral Nerve Stimulation. 
 
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 transcutaneous electrical nerve stimulation (TENS) is covered for the treatment of 
beneficiaries with chronic, intractable pain or acute post-operative pain when one of the following coverage 
criteria, I or II, are met. 
 
I. Acute Post-operative Pain 
 
TENS is covered for acute post-operative pain. Coverage is limited to 30 days (one month's rental) from the 
day of surgery. Payment will be made only as a rental. 
 
A TENS unit will be denied as not reasonable and necessary for acute pain (less than three months duration) 
other than for post-operative pain. 
 
II. Chronic Pain Other than Low Back Pain 
 
TENS is covered for chronic, intractable pain other than chronic low back pain when all of the following 
criteria must be met: 
 The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy. 
Examples of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-
inclusive): 
   - headache 
   - visceral abdominal pain 
   - pelvic pain 
   - temporomandibular joint (TMJ) pain 
 The pain must have been present for at least three months. 
 Other appropriate treatment modalities must have been tried and failed. 
 TENS therapy for chronic pain that does not meet these criteria will be denied as not reasonable and necessary. 
 
TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary.  
 
When used for the treatment of chronic, intractable pain described in section II, the TENS unit must be used by 
the beneficiary on a trial basis for a minimum of one month (30 days), but not to exceed two months. The trial 
period will be paid as a rental. The trial period must be monitored by the treating practitioner to determine the 
effectiveness of the TENS unit in modulating the pain. For coverage of a purchase, the treating practitioner 
must determine that the beneficiary is likely to derive significant therapeutic benefit from continuous use of the 
unit over a long period of time. A 4-lead TENS unit may be used with either 2 leads or 4 leads, depending on 
the characteristics of the beneficiary's pain. If it is ordered for use with 4 leads, the medical record must 
document why 2 leads are insufficient to meet the beneficiarys needs. You can find this information in the 
Local Coverage Determination (LCD): Transcutaneous Electrical Nerve Stimulators (TENS) (L33802). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules 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. 
 
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition, and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 items and services involving the care, treatment, filling, removal or 
replacement of teeth or structures directly supporting the teeth. You can find this rule in the Social Security 
Act, Section 1862(a)(12). 
 
The rules say that treatment for temporomandibular joint (TMJ) syndrome may be covered when the actual 
condition or symptom is medical in nature and the services provided are reasonable and necessary for the 
diagnosis and/or treatment of a medical illness or injury. You can find these rules in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 
15, Section 150.1. 
 
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 for all beneficiaries receiving home health services in 2021 whose services will continue in 
2022, the home health agency (HHA) shall submit a Notice of Admission (NOA) with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. For example, if 
a period of care begins in 2021 and ends on January 10, 2022, the HHA submits an NOA with an admission 
date of January 11, 2022, and then submits a claim when the 30-day period of care is over. The HHA should 
submit the January 11, 2022, admission date on all subsequent claims until the beneficiary is discharged and 
another NOA is required. This is to ensure the claim is matched to the correct NOA and the correct receipt date 
is used for payment. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 
10.1.10.3. 
  
 
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.