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 a Medicare Advantage (MA) organization may specify a network of providers from whom 
enrollees may obtain services. The MA organization must maintain and monitor a network of appropriate 
providers that is sufficient to provide adequate access to covered services to meet the needs of the enrollee. MA 
organizations must arrange for and cover any medically necessary covered benefit outside of the plan provider 
network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to 
meet an enrollee's medical needs. MA organizations 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 MA plan including 
nursing home and community-based services, and behavioral health services. For enrollees undergoing an 
active course of treatment, approval of a prior authorization request for a course of treatment must be valid for 
as long as medically necessary to avoid disruptions in care. 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 in Chapter 3 on pages 38 to 39 of 
the Plan's 2024 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 Decipher is covered for men with prostate cancer: 
 
With localized or biochemically recurrent adenocarcinoma of the prostate (i.e., no clinical evidence of 
metastasis) who have a life expectancy of greater than or equal to 10 years if they are a candidate for and are 
considering (or being considered for) at least 1 of the following: 
 
1. Conservative management and yet would be eligible for definitive therapy (radical prostatectomy (RP), 
radiation or brachytherapy), or; 
2. Radiation therapy and yet would be eligible for the addition of a brachytherapy boost, or; 
3. Radiation therapy and yet would be eligible for the addition of short-term androgen deprivation therapy 
(ADT), or; 
4. Radiation therapy with short-term ADT yet would be eligible for the use of long-term ADT, or; 
5. Radiation with standard ADT yet would be eligible for systemic therapy intensification using next 
generation androgen signaling inhibitors or chemotherapy, or; 
6. Observation post-prostatectomy yet would be eligible for the addition of post-operative adjuvant 
radiotherapy, or; 
7. Salvage radiotherapy post-prostatectomy yet would be eligible for the addition of ADT. 
 
The following criteria must also be met for coverage: 
 
1. The assay is performed on formalin-fixed paraffin embedded (FFPE) prostate biopsy tissue with at least 0.5 
mm of linear tumor diameter or FFPE tissue from a prostate resection specimen, and; 
2. Result will be used to determine treatment according to established practice guidelines, and; 
3. Patient has not received pelvic radiation or ADT prior to the biopsy or prostate resection specimen, and; 
4. Patient is monitored for disease progression according to established standards of care. 
 These rules are found in Local Coverage Determination (LCD): MolDX: Prostate Cancer Genomic Classifier 
Assay for Men with Localized Disease (L38292). 
 
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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 
50.4.1 and 50.4.2. 
 
The rules say that Botulinum toxin type A and botulinum toxin type B have many similarities and as 
experience has been gained, medical consensus has gradually developed that the two toxins have similar, but 
not identical, properties. Each botulinum toxin product is pharmacologically and clinically distinct, and 
therefore, not interchangeable with any other botulinum toxin product. As a result, approved indications for the 
two toxins differ. This A/B MAC has determined that the separate accepted indications for the four toxins will 
be combined into a single list of covered indications in this Local Coverage Determination (LCD) policy. 
However, it is the responsibility of providers to use each drug in accordance with the FDA approved 
indications unless there are valid and documented reasons stating why the unapproved/off label form is used, 
Providers should consult the package insert of each neurotoxin to identify the FDA approved indications for 
each product. You can find this information in the Local Coverage Determination (LCD) L34635: Botulinum 
Toxin Types 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.
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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 Chapter 3 Section: 1.2 of the 
Plan's 2024 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 25% coinsurance for outpatient surgery. The enrollee must pay 25% 
coinsurance per visit to an ambulatory surgical center.You can find this information on page(s) 86 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 $30 copayment for physician/practitioner services, including 
Doctorsoffice visits. The enrollee must pay a $30 copayment for services from a specialist or under certain 
circumstances, treatment by a nurse practitioner, physicians assistant or other non-physician health care 
professional in a specialists office (as allowed under MedicYou can find this information on page(s) 115 to 
120 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. 
 
  
  All the following must be present for coverage eligibility of Next-Generation Sequencing for Solid Tumors: 
 As per National Coverage Determination (NCD) 90.2, this test is reasonable and necessary when: 
o the patient has either: 
 Recurrent cancer 
 Relapsed cancer 
 Refractory cancer 
 Metastatic cancer 
 Advanced cancer (stages III or IV) 
o AND has not been previously tested by the same test for the same genetic content 
o AND is seeking further treatment 
 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 genomic positions required for the 
identification of clinically relevant FDA-approved therapies with a companion diagnostic biomarker as 
well as other biomarkers known to be necessary for clinical decision making for its intended use that 
can be reasonably detected by the test. Because these genes and variants will change as the literature 
and drug indications evolve, they are listed separately in associated documents such as the MolDX

 TA 
forms. 
You can find this rule in the Local Coverage Determination (LCD): MolDX: Next-Generation Sequencing for 
Solid Tumors (L38121). 
 
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 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. This rule is found in Local Coverage Determination (LCD): Pharmacogenomics Testing (L39073). 
 
The rules also state that genetic testing for hereditary cardiovascular disease will be considered medically 
reasonable and necessary if the patient has rigorous disease-appropriate phenotyping to establish clinical 
diagnosis or suspected diagnosis for which the test results would directly impact the management of the 
patients condition. This rule is found in Local Coverage Determination (LCD): Genetic Testing for 
Cardiovascular Disease (L39084). 
 
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 $250 copayment for outpatient diagnostic test, including CT scans. You 
can find this information on page(s) 73 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 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 & 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 page 23 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 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 & 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 
periodic oral evaluation but is limited to twice per calendar year. You also have a $1,000 annual maximum; any 
remaining charges are your responsibility. You can find this information in Chapter 4 on pages 64 through 66 
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 that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
The rules say subluxation may be shown by x-ray or physical exam. You can find this rule in the Centers for 
Medicare & Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 15, Section 240.1.2. 
 
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 the only covered chiropractic service is manual manipulation of the spine to correct 
subluxation. You can find this information on page 55 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 & 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 service. Prior authorization is required. You can find this information on pages 60-62 of the Plans 
2023 Evidence of Coverage (EOC), and on page 9 of the Plan's 2023 Dental Benefit Details.
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 & 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 106 of the Plan's 2024 Evidence of Coverage.