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 cervical traction devices (E0849) 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. 
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. 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. 
 
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 criteria to establish medical necessity for drug testing must be based on patient-specific 
elements identified during the clinical assessment, and documented by the clinician in the patients medical 
record and minimally include the following elements: 
 
Patient history, physical examination and previous laboratory findings 
Current treatment plan 
Prescribed medication(s) 
Risk assessment plan 
Depending on the patients specific substance use history, definitive UDT to accurately determine the specific 
drugs in the patients system may be necessary. Definitive testing may be ordered when accurate and reliable 
results are necessary to integrate treatment decisions and clinical assessment. The frequency and the rationale 
for definitive UDT must be documented in the patients medical record. 
 
a.  For patients with 0 to 30 consecutive days of abstinence, definitive UDT is expected at a frequency not to 
exceed 1 physician-directed testing profile in one week. More than 1 physician-directed testing profile in one 
week is not reasonable and necessary and is not covered by Medicare 
 
b. For patients with 31 to 90 consecutive days of abstinence, definitive UDT is expected at a frequency 1  
physician-directed testing profiles in one month. More than 3 UDT in one month is not reasonable and 
necessary and is not covered by Medicare 
 
c.  For patients with >90 consecutive days of abstinence, definitive UDT is expected at a frequency 1  3 
physician-directed testing profiles in one month. More than 3 UDT in three months is not reasonable and 
necessary and is not covered by Medicare 
 
You can find this information in the Local Coverage Determination (LCD) Controlled Substance Monitoring 
and Drugs of Abuse Testing L36393. 
 
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 a Medicare plan may restrict enrollees 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 outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community-based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 Plans 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 and 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 131 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 state that for diagnostic and/or surveillance purposes, Colon capsule endoscopy (CCE) is medically 
necessary when EITHER of the following criteria are met: 
 
Primary procedure in patients with major risks for Optical Colonoscopy (OC) or moderate sedation as indicated 
from an evaluation of the patient by a board certified or board eligible gastroenterologist, a surgeon trained in 
endoscopy, or a physician with equivalent endoscopic training and EITHER of the following criteria are met:2 
Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR 
Multitarget Stool DNA (sDNA) Test positive OR 
Other evidence of lower GI bleeding in hemodynamically stable patients 
Secondary procedure: 
For the detection or surveillance of colon polyp(s) if the diagnostic OC was incomplete OR 
When an incomplete diagnostic OC was performed for either: 
Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR 
Multitarget Stool DNA (sDNA) Test positive OR 
Other evidence of lower GI bleeding in hemodynamically stable patients 
 
You can find this information in the Local Coverage Determination (LCD) Colon Capsule Endoscopy (CCE) 
L38837. 
 
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 effective for services performed on or after January 27, 2020, CMS has determined that 
NGS as a diagnostic laboratory test is reasonable and necessary and covered nationally for patients with 
germline (inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a treating 
physician and when all of the following requirements are met: 
 
   a. Patient has: 
ovarian or breast cancer; and, 
a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and, 
a risk factor for germline (inherited) breast or ovarian cancer; and 
not been previously tested with the same germline test using NGS for the same germline genetic content. 
   b. The diagnostic laboratory test using NGS must have all of the following: 
FDA-approval or clearance; and, 
results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
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 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 the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
stress fracture. 
spondylosis. 
infection (e.g., discitis). 
tumor (e.g., osteoid osteoma). 
analyze blood flow to an organ, as in the case of myocardial viability. 
differentiate ischemic heart disease from dilated cardiomyopathy. 
Frequency limitations: Medicare Administrative Contractor discretion. 
In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT 
that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET 
performed to evaluate myocardial viability. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 220.12. 
 
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: 
Facet Joint Denervation: 
The thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch 
(MB)) nerves are considered medically reasonable and necessary for patients who meet ALL the following 
criteria: 
1.  
a.  Initial thermal RFA: 
i.  After the patient has had at least 2 medically reasonable and necessary diagnostic 
MBBs, with each 1 providing a consistent minimum of 80% sustained relief of primary 
(index) pain (with the duration of relief being consistent with the agent used); AND 
ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically 
reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least 6 months or at least 50% consistent improvement in the 
ability to perform previously painful movements and ADLs as compared to baseline 
measurement using the same scale 
Frequency Limitation: For each covered spinal region no more than 2 radiofrequency sessions will be 
reimbursed per rolling 12 months. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L38765: Facet Joint Interventions 
for Pain Management. 
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 and 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 pages 68-69 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 state that the covered indications for urinary drug testing (UDT) are: 
- Group A - Symptomatic patients, multiple drug ingestion and/or patients with unreliable history 
- Group B - Treatment for substance abused or dependence 
- Group C - Chronic pain management drug testing for patients on chronic opioid therapy (COT) 
 
Criteria to establish medical necessity for drug testing must be based on patient-specific elements identified 
during the clinical assessment, and documented by the clinician in the patients medical record and minimally 
include the following elements: 
- Patient history, physical examination and previous laboratory findings 
- Current treatment plan 
- Prescribed medication(s) 
- Risk assessment plan 
 
You can find these rules in Local Coverage Determination (LCD) Controlled Substance Monitoring and Drugs 
of Abuse Testing (L36393). 
 
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 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 10 one-way trips. You can find this information on pages 55-56 in 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 state that Type I polysomnography (PSG) is covered when used to aid the diagnosis of OSA in 
beneficiaries who have clinical signs and symptoms indicative of obstructive sleep apnea (OSA) if performed 
attended in a sleep lab facility. 
- The most comprehensive is designated Type I attended facility-based polysomnography (PSG), which 
is considered the reference standard for diagnosing OSA. Attended facility based polysomnogram is a 
comprehensive diagnostic sleep test including at least electroencephalography (EEG), electro-
oculography (EOG), electromyography (EMG), heart rate or electrocardiography (ECG), airflow, 
breathing/respiratory effort, and arterial oxygen saturation (SaO2) furnished in a sleep laboratory 
facility in which a technologist supervises the recording during sleep time and has the ability to 
intervene if needed. 
- Overnight PSG is the conventional diagnostic test for OSA. The American Thoracic Society and the 
American Academy of Sleep Medicine have recommended supervised PSG in the sleep laboratory over 
2 nights for the diagnosis of OSA and the initiation of continuous positive airway pressure (CPAP). 
 
Home sleep testing is not covered for persons with comorbidities. Home Sleep studies are only covered for the 
diagnosis of Obstructive Sleep Apnea. They are not covered for any other sleep disorders or for screening 
asymptomatic persons. You can find these rules in Local Coverage Determination (LCD) Polysomnography 
and Other Sleep Studies L36839 
 
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 raised toilet seats are not covered because they are considered hygienic equipment that is not 
primarily medical in nature. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.1. 
 
The rules say that a raised toilet seat (E0244) is noncovered; therefore, a commode chair that is used as a raised 
toilet seat by positioning it over the toilet is also noncovered. Toilet seat lift mechanisms (E0172) are not 
primarily medical in nature; therefore do not meet the statutory definition of durable medical equipment. They 
are non-covered. You can find this rule in Local Coverage Article Commodes - Policy Article A52461. 
 
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.