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 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). 
 
Medicare rules say that percutaneous vertebral augmentation will be considered medically reasonable and 
necessary when all of the following criteria are met: 
 
Acute or subacute osteoporotic vertebral compression fracture, based on symptom onset and documented by 
advanced imaging demonstrating bone marrow edema on magnetic resonance imaging or bone-scan/single 
photon emission computed tomography scan/computed tomography uptake and the beneficiary is symptomatic 
and is hospitalized with severe pain or is non-hospitalized with moderate to severe pain despite optimal non-
surgical management. You can find this information in the Local Coverage Determination (LCD): 
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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 Abdominal lipectomy/panniculectomy is considered medically reasonable and necessary 
when the pannus or panniculus hangs below the level of the symphysis pubis causing one or more of the 
following conditions: 
- Chronic intertrigo that consistently remains refractory to appropriate medical therapy (e.g., topical 
antifungals, corticosteroids, antibiotics) over a period of three months. 
- Difficulty walking or functional impairment in activities of daily living. 
 
If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted 
above, there should be evidence that the patient has maintained a stable weight for at least six months. For 
patients whose weight loss is the result of bariatric surgery, abdominal lipectomy/panniculectomy should not be 
performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the 
most recent six months. You can find these rules in Local Coverage Determination (LCD) Cosmetic and 
Reconstructive Surgery (L38914). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more 
of the following criteria (1-4) are met: 
 
1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a 
hospital bed, or 
2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain, or 
3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration, or 
4. The beneficiary requires traction equipment, which can only be attached to a hospital bed. 
 
A heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for 
a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 
pounds. You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds And 
Accessories (L33820). 
 
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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 page 52 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 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 another type of pre-symptom memory loop recorder (MLR) is an implantable loop recorder 
(ILR). An ILR 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 more information in Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
National Coverage Determination (NCD): Electrocardiographic Services (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 high frequency chest wall oscillation devices (HFCWO) (E0483) are covered for beneficiaries 
who meet: 
 
   A. Criterion 1, 2, or 3, and 
 
   B. Criterion 4 
 
        1. There is a diagnosis of cystic fibrosis (refer to the ICD-10 code list in the LCD-related Policy Article 
for applicable diagnoses). 
 
        2. There is a diagnosis of bronchiectasis (refer to the ICD-10 code list in the LCD-related Policy Article 
for applicable diagnoses) which has been confirmed by a high resolution, spiral, or standard CT scan and which 
is characterized by: 
 
                a. Daily productive cough for at least 6 continuous months; or 
                b. Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. 
 
        Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed 
diagnosis of bronchiectasis do not meet this criterion. 
 
        3. The beneficiary has one of the following neuromuscular disease diagnoses (refer to the ICD-10 code list 
in the LCD-related Policy Article for applicable diagnoses): 
        Post-polio 
        Acid maltase deficiency 
        Anterior horn cell diseases 
        Multiple sclerosis 
        Quadriplegia 
        Hereditary muscular dystrophy 
        Myotonic disorders 
        Other myopathies 
        Paralysis of the diaphragm 
         4. There must be well-documented failure of standard treatments to adequately mobilize retained 
secretions. 
 
If all of the criteria are not met, the claim will be denied as not reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): High Frequency Chest 
Wall Oscillation Devices (L33785). 
 
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 the type of bill (TOB) is a 4-digit alphanumeric code which gives two pieces of 
information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this 
bill in this particular episode of care. The type of bill accepted for home health PPS requests for anticipated 
payment (RAP), either original or replacement, is 0322. The TOB 0328 may be used to void a previously 
submitted RAP. HH PPS claims may use TOBs 0327, for replacement of a prior claim, 0328 for voiding a prior 
claim, or 0329 for the final claim of the episode of care. This code indicates the HH bill should be processed as 
a debit/credit adjustment to the RAP. You can find this information in the Medicare Claims Processing Manual, 
Chapter 10, Section 40. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that 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 certain requirements are met. This coverage is 
provided for testing that has Food & Drug Administration (FDA) approval or clearance as a companion in vitro 
diagnostic and an FDA-approved or -cleared indication for use in that patients cancer. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-03, 
National Coverage Determinations Manual, Section 90.2. 
 
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 state that local Medicare coverage of biomarkers for oncology must be predicated upon four 
fundamental principles: 
 
   1. First, the biomarkers must have proven clinical validity/utility (CVU).  
   2. Second, to support the medical necessity of the service, there must be acceptance/uptake of specific testing 
into patient management. It is essential that physicians be familiar enough with all specific biomarkers, which 
they order, such that all test results may become clinically actionable. 
   3. Providers managing oncological conditions must demonstrate that the use of biomarkers will be used to 
assist in the management/treatment of the beneficiary. 
   4. Peer-reviewed full manuscript evidence is required to support combination panels for multiple biomarkers, 
particularly regarding their alleged composite clinical validity/utility. For example; such potential billing for 
multiple, diverse biomarkers (e.g., diagnostic/monitoring/prognostic/predictive) can only achieve medical 
necessity when it is clearly evident how each requested biomarker can be individually contributory. 
 
You can find this rule in the Local Coverage Determination (LCD) for Biomarkers for Oncology (L35396). 
 
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. The Plan 
contract says that up to 60 one-way trips are covered each year (limited to ground transportation only). A trip is 
one-way transportation; a round trip is 2 trips. You can find this information on page 4-54 of the 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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 pages 46 to 51 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 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 in Chapter 4 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 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. Covered dental services are 
listed on pages 4-58 to 4-71 in the plan's 2022 Evidence of Coverage. Any service not listed is not covered.
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 facet joint interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria:  
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity.  
You can find this in Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management 
L35936. 
 
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 an epidural steroid injection (ESI) will be considered medically reasonable and 
necessary when the following requirements are met: History, physical examination, and concordant 
radiological image-based diagnostic testing that supports one of the following: -Lumbar, cervical, or thoracic 
radiculopathy, radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte 
complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis OR -Post-
laminectomy syndrome, OR-Acute herpes zoster associated pain. You can find this rule in the Local Coverage 
Determination (LCD) - L36920, Epidural Steroid Injections 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.