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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
The rules say that providers/suppliers 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 also say that the Physician Fee Schedule Status Indicator B means that payment for covered services 
is always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. 
 
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 also says that only manual manipulation of the spine to correct subluxation is covered. Other services 
performed by a chiropractor are not covered by the Plan. You can find this information on page 51 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 Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 92 of the Plan's 2024 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 sacroiliac joint denervation (also called Radiofrequency Ablation or RFA) is not considered 
reasonable and necessary. You can find this information in the Local Coverage Determination (LCD): 
Sacroiliac Joint Injections and Procedures (L39402). 
 
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 & 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 does not include 
implants or custom fabricated abutments. You can find this information on pages 53, and 94-97 of the Plans 
2024 Evidence of Coverage (EOC) and in the Quick Reference Guide.
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 chronic venous disorders of the lower extremity incorporate a spectrum of morphologic and 
functional abnormalities of the venous system. Symptoms and findings include pain, leg heaviness, aching, 
swelling, skin dryness, tightness, itching, irritation, and muscle cramps. Clinical signs of venous disease 
include dilated veins, leg edema, skin changes (lipodermatosclerosis; a fibrosing dermatitis of the subcutaneous 
tissue), and skin ulceration. The presence of symptoms and clinical signs of venous disease correlates with the 
presence of venous reflux (in the superficial or deep veins) and/or venous obstruction identified on duplex 
ultrasound. 
 
Sclerotherapy is a minimally invasive percutaneous technique using chemical irritants, that is, liquid and foam 
sclerotherapy techniques, to close unwanted veins. Sclerotherapy for treatment of varicose veins or reflux is 
followed by compression therapy of the affected lower limb using either elastic or conventional bandaging. 
 
You can find these rules in the Local Coverage Determination (LCD) Treatment of Varicose Veins of the 
Lower Extremities L39121. 
 
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 total knee arthroplasty (TKA) is considered reasonable and necessary for individuals 
with one or more of the following: 
 
1. Advanced Joint disease and all of the following: 
a. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI); and 
b. Pain or functional disability attributable to the advanced joint disease; and 
c. Unsuccessful non-surgical medical management, when appropriate, and attempted for a minimum of 3 
months. (When non-surgical medical management is not appropriate, the medical record must clearly document 
the basis for that conclusion); 
or 
2. Failure of a previous osteotomy; or 
3. Distal femur fracture; or 
4. Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or 
5. Failure of previous unicompartmental knee replacement; or 
6. Avascular necrosis of the knee; or 
7. Proximal tibia fracture 
 
TKA is not considered reasonable or necessary when none of the criteria above are met. 
 
TKA is not considered reasonable or necessary when one or more of the following contraindications are 
present: 
 
- Active infection of the hip or knee joint or active systemic bacteremia; and/or 
- Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned 
surgical site of the hip or knee; and/or 
- Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral 
neck fracture 
 
You can find this information in the Local Coverage Determination (LCD): Total Joint Arthroplasty (L36039).  
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 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 & 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 12 one-way trips. You can find this information on pages 115-116 in the Plans 2024 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the primary indication of a diagnostic facet joint procedure is to diagnose whether the 
patient has facet syndrome.1,4,7,12,16 Intraarticular (IA) facet block(s) are considered medically reasonable 
and necessary as a diagnostic test only if MBB cannot be performed due to specific documented anatomic 
restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must 
be clearly documented in the medical record and made available upon request. 
 
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).11 
 
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.7 
 
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. 
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).11 
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be 
considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator 
cannot always be identified with the initial and confirmatory diagnostic procedure. 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L33930. 
 
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 cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if both 
of the following criteria are met: 
 
1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 
2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the 
beneficiary tolerated the selected device. 
 
You can find this rule in the Local Coverage Determination (LCD) - Cervical Traction Devices (L33823). 
 
The rules say that cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 
and 2 above and either criterion A, B or C below has been met: 
 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received treatment 
for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a 
chin halter is unable to be utilized; or, 
C. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will 
be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - 
Cervical Traction Devices (L33823). 
 
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 continued coverage of a positive air pressure (PAP) device (E0470 or E0601) beyond the 
first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after 
initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the 
beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after November 
1, 2008, documentation of clinical benefit is demonstrated by:  
 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and,  
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. Adherence 
to therapy is defined as use of PAP more than or equal to 4 hours per night on 70% of nights during a 
consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
This rule is found in Medicare Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices 
for the Treatment of Obstructive Sleep Apnea (L33718). 
 
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 a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 90 of the Plan's 2024 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 on page 37 of the Plan's 2024 
Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the clinical record must clearly show the use of or intent to prescribe a drug that has known 
drug-gene interactions that require a PGx test to be ordered to define the safe use of that drug in that patient. 
 
If a treating clinician orders a single gene test or a test for a particular allele(s), but as a matter of operational 
practicality, the laboratory tests that single gene or allele on a platform that looks for variants in other genes / 
alleles as well, that particular test done in that particular instance is considered a single gene / allele test for 
coverage purposes. In this scenario the provider may bill for the component of the test that was reasonable and 
necessary (in this example, the single gene test). 
 
A multi-gene panel is considered reasonable and necessary if more than one single gene on that panel would be 
considered reasonable and necessary for safe use of the medication in question or if multiple drugs are being 
considered (each fulfilling the criteria of actionable gene-drug interactions identified above) that have different 
relevant genes. Additionally, a gene panel must contain at a minimum all the necessary relevant gene/allele 
content required for their indicated use to meet clinical utility requirements. Such minimum criteria are 
determined by experts including relevant associations such as the Association for Molecular Pathology and are 
considered during the technical assessment. A multi-gene panel is not considered reasonable and necessary if 
only a single gene on the panel is considered reasonable and necessary. 
 
If two or more single genes are tested, rather than a multi-gene panel, then the record must reflect that a 
clinician individually ordered each gene, and each single gene must individually be reasonable and necessary at 
the time they are ordered. 
 
The ordering provider of a PGx test is restricted to providers who have the licensure, qualifications, and 
necessary experience / training to both diagnose the condition being treated and also to prescribe medications 
(the provider must be able to do both) for the condition either independently or in an arrangement as required 
by all the applicable state laws. 
 
You can find this information in the Local Coverage Determination (LCD) MolDX: Pharmacogenomics 
Testing L38394.  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.