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 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 67 to 68 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that an L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all 
of criteria 1 - 4 or criterion 5 is met: 
1. Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 
10 degrees (i.e., a nonfixed contracture); and, 
2. Reasonable expectation of the ability to correct the contracture; and, 
3. Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; 
and, 
4. Used as a component of a therapy program which includes active stretching of the involved muscles 
and/or tendons. 
5. The beneficiary has plantar fasciitis. 
If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range 
of motion must be measured with a goniometer and documented in the medical record. There must be 
documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or 
caregiver (at home). 
 
An L4396 or L4397 and replacement interface (L4392) will be denied as not reasonable and necessary if the 
contracture is fixed. Codes L4396, L4397 and L4392 will be denied as not reasonable and necessary for a 
beneficiary with a foot drop but without an ankle flexion contracture. A component of a static/dynamic ankle-
foot orthosis that is used to address positioning of the knee or hip will be denied as not reasonable and 
necessary because the effectiveness of this type of component is not established. 
 
You can find this information in the Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot 
Orthosis (L33686). 
 
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. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 82-83 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 state that FDA-approved hypoglossal nerve neurostimulation is considered medically reasonable and 
necessary for the treatment of moderate to severe obstructive sleep apnea when all of the following criteria are 
met: 
 
    Beneficiary is 22 years of age or older; and 
    Body mass index (BMI) is less than 35 kg/m2; and 
    A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and 
    Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% of the 
total AHI); and 
    AHI is 15 to 65 events per hour; and 
    Beneficiary has documentation that demonstrates CPAP failure (defined as AHI greater than 15 despite 
CPAP usage) or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week or the CPAP has 
been returned) including shared decision making that the patient was intolerant of CPAP despite consultation 
with a sleep expert; and 
    Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy 
(DISE) procedure; and 
    No other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per 
standardized tonsillar hypertrophy grading scale). 
 
You can find this information in the Local Coverage Determination (LCD) Hypoglossal Nerve Stimulation for 
the Treatment of Obstructive Sleep Apnea L38398. 
 
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 beginning January 1, 2023, the CPT is merging the two E/M visit families currently titled 
"Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services" and "Home Services." The new 
family will be titled "Home or Residence Services. The codes in this family (CPT codes 99341 - 99350) will be 
used to report E/M services furnished to a patient residing in their home, in an assisted living facility, in a 
group home (that is not licensed as an intermediate care facility for individuals with intellectual disabilities), in 
a custodial care facility, or in a residential substance abuse treatment facility. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, 
Chapter 12, Section 30.6.14. 
 
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 for each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. You can find this information in Medicare's 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.
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 to report a Molecular Diagnostic Test service, please submit the following claim 
information: 
 
   - Select appropriate CPT code 
   - Enter 1 unit of service (UOS) 
   - Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field 
for the following Part B claim field/types: 
       -- Loop 2400 or SV101-7 for the 5010A1 837P 
       -- Item 19 for paper claim 
   - Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field 
for the following Part A claim field/types: 
       -- Line SV202-7 for 837I electronic claim 
       -- Block 80 for the UB04 claim form 
 
You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: MolDX: Molecular 
Diagnostic Tests (MDT) (A57526). 
 
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 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 on pages 39-43 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 one to two levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a three or four-level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. A session is a time period, which includes all 
procedures that are performed during the same day. 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. 
 
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 covers application of cellular and/or tissue products (CTPs) to Ulcers or Wounds 
with Failed Response that are: 
 
 Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone 
or sinus tracts, with a clean granular base unless the CTP package label indicates the CTP is approved 
for use involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean 
granular base ; 
 Skin deficit at least 1.0 cm2 in size; 
 Clean and free of necrotic debris or exudate; 
 Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by 
physical examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure greater than 
30mm Hg); 
 For diabetic foot ulcers, the patients medical record reflects a diagnosis of Type 1 or Type 2 Diabetes 
and also reflects medical management for this condition. 
 
CTP grafts will be allowed for the episode of wound care in compliance with FDA guidelines for the specific 
product (see utilization guidelines) not to exceed 10 applications or treatments. In situations where more than 
one specific product is used, it is expected that the number of applications or treatments will still not exceed 10. 
Product change within the episode of wound is allowed, not to exceed the 10-application limit per wound per 
12-week period of care. You can find this rule in the Local Coverage Determination for Wound Application of 
Cellular and/or Tissue Based Products (CTPs), Lower Extremities, L36690. 
 
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 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 specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
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 33 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 18 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 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 specific 
dental procedure codes included in a dental benefits chart. Surgical placement of implant body (D6010) is not 
on the list and therefore not covered by the Plan's dental benefit. You can find this information in Chapter 4 on 
pages 107 to 120 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 Grievance Manual, Section 50.12.1. 
 
The rules say that Medicare Advantage (MA) plans participating in Part B step therapy must disclose that Part 
B drugs may be subject to step therapy requirements in the plans Annual Notice of Change (ANOC) and 
Evidence of Coverage (EOC) documents that are provided to enrollees prior to the Medicare Open Enrollment 
period to assist them in making Plan selections for the upcoming year. You can find this information in the on 
the CMS website at https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-prior-authorization-and-
step-therapy-part-b-drugs and also in this memo: https://www.cms.gov/Medicare/Health-
Plans/HealthPlansGenInfo/Downloads/MA_Step_Therapy_HPMS_Memo_8_7_2018.pdf 
 
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.