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 following indications for BRCA1 and BRCA2 testing are covered by Medicare: 
 
Criteria for Testing 
1. Individual with breast, ovarian, pancreatic, or prostate cancer from a family with a known deleterious 
BRCA1 or BRCA2 gene mutation 
2. Individual with a personal history of ovarian cancer 
3. Individual with a breast cancer diagnosis meeting any of the following criteria:  
I. Diagnosed 45 y 
II. Triple negative breast cancer (estrogen receptor (ER) negative, progesterone receptor (PR) 
negative, and human epidermal growth factor receptor 2 (HER2) negative) breast cancer 
diagnosed  60 y 
III. Diagnosed at 46-50 y with:  
a) An additional breast cancer primary 
b) 1 first, second, or third degree relative with breast cancer at any age, or 
c) 1 first, second, or third degree relative with prostate cancer (Gleason score 7), or 
d) An unknown or limited family history 
IV. Breast cancer diagnosed at any age, and  
a) 1 first, second, or third degree relative with breast cancer 50 y, or 
b) 1 first, second, or third degree relative with ovarian cancer at any age, or 
c) 1 first, second, or third degree relative with metastatic prostate cancer or pancreatic 
cancer at any age, or 
d) 2 additional diagnoses of breast cancer at any age in patient and/or in close blood 
relative, or 
e) A first, second, or third degree male relative with breast cancer 
f) For an individual of ethnicity associated with higher mutation frequency (e.g., Ashkenazi 
Jewish) no additional family history may be required 
V. Male breast cancer 
4. Personal history of prostate cancer (Gleason score 7) at any age with: 
I. 1 first, second, or third degree relative with ovarian cancer at any age, or 
II. 1 first, second, or third degree relative with breast cancer 50 y, or 
III. 1 first, second, or third degree relative
 
pancreatic cancer at any age, or IV. 1 first, second, or third degree relative
 
with metastatic prostate cancer at any age, or 
V. 2 first, second, or third degree relatives with breast cancer and/or pancreatic cancer and/or 
prostate cancer (any grade) at any age, or 
VI. Ashkenazi Jewish ancestry 
5. Personal history of pancreatic cancer at any age 
6. Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) 
7. BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of 
germline mutation analysis 
You can find more information in Local Coverage Determination (LCD): MolDX: BRCA1 and BRCA2 
Genetic Testing (L36082). 
 
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 48 one-way trips per year for medical appointments in any medical facility and picking up prescriptions 
in pharmacies. You can find this information on page 101 of the Plans 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 state that Elevating legrests are covered if: 
1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree 
flexion at the knee; or 
2. The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or 
3. The beneficiary meets the criteria for and has a reclining back on the wheelchair. 
 
You can find this information in the Medicare Coverage Database Local Coverage Determination (LCD) 
Wheelchair Options/Accessories L33792. 
 
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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that diagnostic tests are covered by the Plan. The Plan contract says that enrollees must pay a 
30% coinsurance for each out-of-network Medicare-covered diagnostic procedure and test. You can find this 
information on pages 104 to 105 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 IV therapy or transfusion services. You can find this 
information on page 80 of the Plan's 2021 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 covers medical nutrition therapy services (MNT) for certain enrollees who have 
diabetes or a renal disease. You can find this rule at 42 CFR Section 410.132(b)(4) and in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage 
Determinations Manual, Chapter 1, Section 180.1. 
 
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 Plan 
contract also says that medical nutrition therapy is for people with diabetes, renal (kidney) disease (but not on 
dialysis), or after a kidney transplant when ordered by your doctor. You can find this information on page 80 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 state that a POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I 
are also met. 
 
    The beneficiary is able to: 
        Safely transfer to and from a POV, and 
        Operate the tiller steering system, and 
        Maintain postural stability and position while operating the POV in the home. 
    The beneficiarys mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are 
sufficient for safe mobility using a POV in the home. 
 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the POV that is provided. 
 
    The beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and greater 
than or equal to 95% of the weight capacity of the next lower weight class POV  i.e., a Heavy Duty POV is 
covered for a beneficiary weighing 285  450 pounds; a Very Heavy Duty POV is covered for a beneficiary 
weighing 428  600 pounds. 
 
    Use of a POV will significantly improve the beneficiarys ability to participate in MRADLs and the 
beneficiary will use it in the home. 
 
    The beneficiary has not expressed an unwillingness to use a POV in the home. 
 
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable 
and necessary. 
 
Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. 
Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. 
 
If a POV will only be used outside the home, see related Policy Article for information concerning 
noncoverage. 
 POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND 
INCLUDING 300 POUNDS 
 
If the PWC base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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 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 $40 copayment for each specialist visit. You can find this information 
on pages 87-89 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 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 $90 copayment for diagnostic procedures and tests at an outpatient 
hospital setting. You can find this information on page 99 of the Plan's 2021 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 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 up to 72 one-way trips each ear. Each one-way trip must not exceed 50 miles o driving distance. You 
can find this information on page 4-54 of the Plans 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 on pages 45 and 49 of the Plan's 
2021 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 $5 copayment for each Medicare-covered primary care office visit 
including Some telehealth services including consultation, diagnosis, and treatment by a physician or 
practitioner. You can find this information in Chapter 4 on pages 106 to 108 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. 
Contrast angiography is considered medically reasonable and necessary and recognized as the gold standard for 
defining any of the following: 
  
  1. The presence/extent of vascular occlusive disease and thromboembolic phenomena; 
2. Etiology of hemorrhage; 
3. Vascular supply of tumors; 
4. Outlining vascular anatomy for planning and determining the effect of therapeutic procedures; 
5. The presence, location, and anatomy of extracranial and intracranial aneurysms and vascular 
malformations; 
6. The diagnosis of the nature and extent of congenital or acquired vascular abnormality; 
and 
7. The relevant vascular anatomy for determining the effect of therapeutic measures. 
Candidates for these procedures should meet at least one of the following criteria: 
1. Documented symptoms of ischemic cerebral disease; 
2. Documented results from previous noninvasive test(s) indicating severely stenotic carotid disease or 
severely ulcerated carotid disease; 
3. Medical history consistent with known or suspected trauma, tumor or other intracranial anomalies; 
4. Medical history consistent with upper extremity claudication, acute or chronic arterial trauma, thoracic 
outlet obstruction disease, certain vasculitides, and subclavian steal; 
5. Surgical or percutaneous correction of the occlusive disease must be beneficial to the candidates 
clinical status. 
You can find more information in Local Coverage Determination (LCD): Thoracic Aortography and Carotic, 
Vertebral, and Subclavian Angiography (L35035). 
 
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). 
 
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 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 $175 copayment for outpatient hospital services other than emergency 
room visits and for Medicare-covered dialysis services. You can find this information on page 93 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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that there is a $110 deductible for all items and services except those specifically excluded 
by the Plan contract. You can find this information on pages 4-2 to 4-3 of the Plan's 2022 Evidence of 
Coverage (EOC).