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 noninvasive testing in the outpatient setting to assess for coronary artery disease (CAD) and 
left ventricular (LV) dysfunction may be accomplished by utilizing conventional exercise stress testing without 
imaging or by utilizing exercise or pharmacologic stress testing with imaging. 
 
Cardiovascular stress testing, also referred to as exercise stress test (EST), exercise electrocardiogram, exercise 
treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information 
about how the heart responds to exertion. 
 
Types of stress testing with imaging addressed in this LCD include stress echocardiography, single photon 
emission computed tomography (SPECT) myocardial perfusion imaging (MPI), positron emission tomography 
(PET) MPI, and cardiac magnetic resonance imaging (CMR). Stress testing with imaging can be performed 
with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine, regadenoson, or other 
provocative agents). 
 
Stress echocardiography, SPECT MPI, PET MPI and CMR are considered equivalent diagnostic tests. 
However, in addition to myocardial ischemia, stress echocardiography can provide information that is not 
obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic 
obstruction. The most commonly performed myocardial perfusion imaging are single (at rest or stress) and 
multiple (at rest and stress) SPECT studies. The CMR can also distinguish scar from hibernating myocardium, 
provide information about valvular function, the presence of myocardial fibrosis, the presence of 
morphological abnormalities, and provide an assessment of dynamic obstruction without radiation exposure. 
This is especially valuable in patients in whom good quality echocardiography images could not be obtained 
due to technically difficult acoustic windows. 
 
In many instances, EST may be combined with imaging procedures, such as MPI, echocardiography, or other 
imaging procedures. 
 
 
 Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests 
including echocardiography and nuclear cardiac imaging. However, selection of the test should be made within 
the context of other testing modalities so that the expected information does not become redundant. 
 
You can find these rules in the Local Coverage Determination (LCD) Cardiology Non-emergent Outpatient 
Stress Testing L38396. 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. You can find this rule in the Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L36256). 
 
The rules state that the date of service (DOS) for laboratory tests must be the date the specimen was collected. 
One exception is testing on stored specimens which only changes the DOS if it would be medically 
inappropriate to have collected the sample other than during the hospital procedure for which the patient was 
admitted. There are other exceptions for chemotherapy sensitivity testing on live tissue and advanced 
diagnostic laboratory/molecular pathology tests. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
16, Section 40.8. 
 
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 PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
 
    1. Inclusion criteria (ALL are required): 
        a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) based on symptom onset, and 
documented by advanced imaging  (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) 
        b. Symptomatic (ONE): 
            i. Hospitalized with severe pain              
            ii. Non-hospitalized with moderate to severe pain despite optimal non-surgical management (NSM) 
(ONE): 
                1. Worsening pain 
                2. Stable to improved pain with at least 2 of the following: 
                    A. Progression of vertebral body height loss 
                    B. > 25% vertebral body height reduction 
                    C. Kyphotic deformity 
                    D. Severe impact of VCF on daily functioning              
 c. Continuum of Care (Both): 
i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis 
education for subsequent treatment as indicated.  
            ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program.  
2. Exclusion criteria (Can have NONE of the following): 
        a. Absolute contraindication 
            i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
           ii.  Osteomyelitis, discitis or active systemic or surgical site infection 
            iii. Pregnancy 
        b. Relative contraindication 
            i. Greater than three vertebral fractures per procedure 
            ii. Allergy to bone cement or opacification agents             iii. Uncorrected Coagulopathy 
            iv. Spinal instability 
            v. Myelopathy from the fracture 
            vi. Neurologic deficit 
            vii. Neural impingement 
            viii. Fracture retropulsion/canal compromise 
 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34106). 
 
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 September 29, 2008, the Centers for Medicare 
and Medicaid Services has determined that TIPs are not reasonable and necessary for the treatment of low back 
pain. Therefore, TIPs, which include procedures that employ the use of a radiofrequency energy source or 
electrothermal energy to apply or create heat and/or disruption within the disc for the treatment of low back 
pain, are noncovered. 
 
You can find this information in the National Coverage Determination (NCD) Thermal Intradiscal Procedures 
(TIPs) 150.11. 
 
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.
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 24 one-way rides every year to and from medically related appointments and the pharmacy. You 
can find this information on pages 75-76 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 rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 24 one-way trips each year. Each one-way trip must not exceed 50 miles of driving distance. You 
can find this information on pages 88 to 89 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 rules say that claims for services furnished on or after January 1, 2010, must be filed no later than the close 
of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR Section 
424.44(a). 
 
The rules say that a party may request a contractor reopen and revise its initial determination within 1 year 
from the date of the initial determination or redetermination for any reason. You can find this information in 
the Centers for Medicare and Medicaid Services (CMS), Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 34, Section 10.6.2. 
 
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 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 also says if you use an out-of-network provider, your share of the costs for your covered services may 
be higher. You can find this information on pages 38 to 39 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 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 the Plan covers items and services in accordance with Medicare rules. The Plan contract says 
that enrollees pay a 25% coinsurance for Medicare-covered vision visits. The contract also says refractions are 
not covered out-of-network. You can find this information on page 127 of the Plan's 2022 Evidence of 
Coverage. 
 
The Plan contract says that enrollees pay a 25% coinsurance for each out-of-network Medicare-covered other 
diagnostic test. You can find this information on page 108 of the Plans 2022 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 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. 
 
PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP) is covered in patients with osteoporotic VCF 
when BOTH the following: 
1. Inclusion criteria (ALL are required): 
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom 
onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) (1-3,10,25,27) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score  8) (4-7) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-
surgical management (NSM) (10) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5) (with  2 of the following): 
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17 c. Continuum of care (10) (Both are required) 
i. All patients presenting with VCF should be referred for evaluation of BMD and 
osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
Local Coverage Determination (LCD): LCD - Percutaneous Vertebral Augmentation (PVA) for Vertebral 
Compression Fracture (VCF) (L38201). 
 
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 a test panel is a single test with multiple components and is characterized by a single unit of 
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. If additional organisms are not included in a panel, 
testing for those organisms separately may be reasonable and necessary when ordered in addition to the panel 
and supported by documentation in the medical record. You can find this information in the Centers for 
Medicare and Medicaid Services, Local Coverage Article (LCA): Billing and Coding: MolDX: Molecular 
Syndromic Panels for Infectious Disease Pathogen Identification Testing (A58761).  
 
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 an Implantable (or Insertable Loop) Recorder (ILR), another type of pre-symptom Memory 
Loop Recorder (MLR), is implanted subcutaneously in a patients upper left chest and may remain implanted 
for many months. An ILR is used when syncope is thought to be cardiac-related but is too infrequent to be 
detected by either a HolterTM monitor or a traditional pre-symptom MLR. You can find this information in the 
Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare 
National Coverage Determinations (NCD) Manual, Section 20.15. 
 
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 knee orthoses (KO) are covered under the Medicare braces benefit (Social Security Act 
1861(s)(9)). For coverage under this benefit, the orthosis must be a rigid or semi-rigid device, which is used 
for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a 
diseased or injured part of the body. Items that are not sufficiently rigid to be capable of providing the 
necessary immobilization or support to the body part for which it is designed do not meet the statutory 
definition of the braces benefit. Items that do not meet the definition of a brace are statutorily noncovered, no 
benefit. 
 
A knee flexion contracture is a condition in which there is shortening of the muscles and/or tendons with the 
resulting inability to bring the knee to 0 degrees extension or greater (i.e., hyperextension) by passive range of 
motion. (0 degrees knee extension is when the femur and tibia are in alignment in a horizontal plane). A knee 
extension contracture is a condition in which there is shortening of the muscles and/or tendons with the 
resulting inability to bring the knee to 80 degrees flexion or greater by passive range of motion. A contracture 
is distinguished from the temporary loss of range of motion of a joint following injury, surgery, casting, or 
other immobilization.  
 
A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a 
knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation 
control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related 
Policy Article. 
 
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by 
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, 
anterior/posterior Drawer test). Code L2397 component or features can be and physically incorporated in the specified prefabricated base 
orthosis but are considered not reasonable or necessary. 
 
You can find these rules in Local Coverage Determination (LCD) Article - Knee Orthoses - Policy Article 
(L33318) 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.