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  pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
    -The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
 
    -The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label. You can find this information in 
Local Coverage Determination (LCD): Pharmacogenomics Testing (L39073). 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
 
a. Patient has: 
 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
b. The diagnostic laboratory test using NGS must have: 
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in the National Coverage Determination (NCD)  Next Generation Sequencing (NGS) 
(90.2)  Effective January 27, 2020. 
 
The rules say 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: 
i. ovarian or breast cancer; and, 
ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and, 
iii. a risk factor for germline (inherited) breast or ovarian cancer; and iv. 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: 
 
 
i. FDA-approval or clearance; and, 
ii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
You can find this rule in the National Coverage Determination (NCD)  Next Generation Sequencing (NGS) 
(90.2)  Effective January 27, 2020. 
 
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 the reasonable useful lifetime of durable medical equipment is determined through program 
instructions. In the absence of program instructions, Part A/Part B Medicare Administrative Contractor 
(MAC)s (B) may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 
years. Computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not 
the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but 
not actual replacement) for medically necessary equipment owned by the beneficiary. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2- Repairs, Maintenance, 
Replacement, and Delivery (C). 
 
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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when ALL of the following are true: 
 
    The patient has a personal history of melanoma AND: 
        -Either: 
            -Has Stage T1b and above OR 
            -Has T1a with documented concern about adequacy of microstaging 
        -Is undergoing workup or being evaluated for treatment, AND 
        -Does not have metastatic disease AND 
        -Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or 
other information is >5% AND 
        -Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended use 
of the test 
 
You can find this information in Local Coverage Determination (LCD): MolDX: Melanoma Risk Stratification 
Molecular Testing (L37748). 
 
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 the following must be present for coverage eligibility: 
 
    -For tests that are specifically indicated in patients who are known to have a myeloid malignancy at the time 
of testing, NCD 90.2 applies. 
    -The patient has a diagnosis of AML, MDS, or MPN. AML, MDS, and MPN are herein classified as 
refractory and/or metastatic cancers and fulfil the NCD 90.2 criteria. 
    -The test has satisfactorily completed a TA by MolDX for the stated indications of the test. 
    -The assay performed includes at least the minimum genes and positions indicated for its intended use, as 
described in an associated coverage Article or found in the TA forms. 
    -For patients that do not have a diagnosis of a myeloid malignancy, where one is suspected, the patient must 
have an undefined cytopenia for greater than 4 months, other possible causes have been reasonably excluded. 
    -Testing is performed on bone marrow biopsies, bone marrow aspirates, bone marrow clots, peripheral blood 
samples, or extramedullary sites suspected of harboring a myeloid malignancy. You can find this information 
in MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected 
Myeloid Malignancies (L38123). 
 
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 only certain diagnoses support the medical necessity for the use of Botox (J0585). Occipital 
neuralgia, M54.81, is not listed as a diagnosis that supports medical necessity. You can find this information 
and a full list of covered diagnoses in Local Coverage Article: Billing and Coding: Botulinum Toxin Types A 
and B (A57186). 
 
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 says that examples of inpatient psychiatric admission criteria include (but are not limited to): 
 
1. Threat to self- requiring 24-hour professional observation: 
 suicidal ideation or gesture within 72 hours prior to admission; 
 self- mutilation (actual or threatened) within 72 hours prior to admission; 
 chronic and continuing self- destructive behavior (e.g., bulimic behaviors, substance abuse) that poses a 
significant and/or immediate threat to life, limb, or bodily function. 
2. Threat to others requiring 24-hour professional observation: 
 assaultive behavior threatening others within 72 hours prior to admission 
 a significant verbal threat to the safety of others within 72 hours prior to admission. 
3. Command hallucinations directing harm to self or others where there is the risk of the patient taking action 
on them. 
 
4. Acute disordered/bizarre behavior or psychomotor agitation or retardation that interferes with the activities 
of daily living (ADLs) so that the patient cannot function at a less intensive level of care during evaluation and 
treatment. 
 
  
5. Cognitive impairment (disorientation or memory loss) due to an acute psychiatric disorder that endangers the 
welfare of the patient or others. 
 
6. For patients with a dementing disorder for evaluation or treatment of a psychiatric comorbidity (e.g., risk of 
suicide, violence, severe depression) warranting inpatient admission. 
 
7. A mental disorder causing major disability in social, interpersonal, occupational, and/or educational 
functioning that is leading to dangerous or life-threatening functioning, and that can only be addressed in an 
acute inpatient setting. 
 
8. A mental disorder that causes an inability to maintain adequate nutrition or self-care, and family/community 
support cannot provide reliable, essential care, so that the patient cannot function at a less intensive level of 
care during evaluation and treatment. 
 
9. Failure of outpatient psychiatric treatment so that the beneficiary requires 24-hour professional observation 
and care. Reasons for the failure of outpatient treatment could include: 
 increasing severity of psychiatric symptoms; 
 noncompliance with medication regimen due to the severity of psychiatric symptoms; 
 inadequate clinical response to psychotropic medications; 
You can find this information at Local Coverage Determination (LCD)-Psychiatric Inpatient Hospitalization 
(L34570). 
 
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 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 the 
requested item or service but is limited to four pontics per plan year. You can find this information on pages 
129-130 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 a $270 copayment for ambulance services, including stabilization 
services. You can find this information on page(s) 60-61 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 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 the 
requested item or service but is limited two implants per year. You can find this information on pages 129-130 
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 a $125 copayment for outpatient hospital services. You can find this 
information on page(s) 23 of the Plan's 2023 Schedule of Cost Sharing.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $55 copayment for urgently needed services. You can find this 
information on page(s) 91 of the Plan's 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for outpatient hospital services. You can find this 
information on page 90 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 41 to 42 of 
the Plan's 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $50 copayment for outpatient diagnostic tests. You can find this 
information on page(s) 96 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 enrollees must pay a $25 copayment for physician/practitioner services/specialist. You can 
find this information on page(s) 108 of the Plan's 2022 Evidence of Coverage.