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 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 core 
buildup services but are subject to certain clinical requirements. You can find this information on pages 83-84 
and 89-91 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 there are two applications of molecular biomarkers to risk-stratify patients at increased risk 
for prostate cancer: 
 
I. A non-invasive or minimally invasive test, the results of which are obtained to inform the decision to 
perform an initial biopsy (pre-biopsy). 
II. A test performed to further refine risk when a biopsy has been performed but does not clearly indicate 
malignancy on histopathologic examination (post-biopsy). Such a test can potentially obviate the need for a 
repeat biopsy. 
 
You can find this information in the Local Coverage Determination (LCD): MolDX: Molecular Biomarkers to 
Risk-Stratify Patients at Increased Risk for Prostate Cancer (L39005). 
 
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. 
 
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 53 of the Plans 2023 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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
The rules also state that there are certain providers who are not eligible to enroll in Medicare. One such 
provider type is a substance abuse facility. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 
10, Section 10.2.8. 
 
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 if the base pneumatic compression device (PCD) is not covered, related accessories are not 
eligible for reimbursement. Claims for related items will be denied as not reasonable and necessary. You can 
find this information in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules say that effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; 
and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to 
specify treatment options. 
You can find this rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) 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 it has not been established that a moist electric heating pad (E0215) or water circulating 
heat pad with pump (E0217) is reasonable and necessary compared to a standard electric heating pad (E0210); 
therefore, if code E0215 or E0217 is provided it will be denied as not reasonable and necessary. 
You can find this rule in the Local Coverage Determination (LCD) 
Heating Pads and Heat Lamps, L33784. 
 
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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
The rules say that an 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: 
o Chronic intertrigo that consistently remains refractory to appropriate medical therapy 
(e.g., topical antifungals, corticosteroids, antibiotics) over a period of three months. 
o 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. 
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L35090). 
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 polyethylene-glycol (PEG) hydrogel is covered once in patients with clinically localized 
prostate cancer with both the following:  
1. Inclusion criteria including all of the following: 
a. Low* or Favorable Intermediate Prostate Cancer Risk Group (AUA or NCCN criteria) 
b. Dose escalated ( 76 Gy) conventional fractionation (1.8-2 Gy fractions) or moderate 
hypofractionation (HFX) (2.4-3.4 Gy fractions) IG-IMRT planned 
c. Eastern Cooperative Oncology Group (ECOG) performance status  1 
d. Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side 
effects due to at least one of the following: 
i. Anatomic geometry precluding ideal rectal constraints  
o Conventional fractionation (V70 <10%, V65 <20%, V40 <40%) 
o Moderate HPX (dose constraints not yet standardized; employ those used in the 
supporting phase III trials) 
ii. Medication usage (e.g., anticoagulants) 
iii. Comorbid conditions (e.g., increased age, Hx MI or CHF) 
2. No Exclusion criteria including all of the following: 
a. Less than 5-year life-expectancy and asymptomatic 
b. Prior prostate cancer treatment (surgery or RT) 
c. Active bleeding disorder or clinically significant coagulopathy 
d. Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, 
anorectal IBD) 
e. Prostate volume > 80 cc 
*Life expectancy  20 y (very low risk);  10 y (low risk) 
You can find this information in Local Coverage Determination (LCD): Prostate Rectal Spacers (L37485). 
 
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 there are a number of devices available to induce emptying of the urinary bladder by using 
electrical current which forces the muscles of the bladder to contract. These devices (commonly known as 
bladder stimulators or pacemakers) are characterized by the implantation of electrodes in the wall of the 
bladder, the rectal cones, or the spinal cord. While these treatments may effectively empty the bladder, the 
issue of safety involving the initiation of infection, erosion, placement, and material selection has not been 
resolved. Further, some facilities previously using electronic emptying have stopped using this method due to 
the pain experienced by the patient. 
 
Indications and Limitations of Coverage 
 
The use of spinal cord electrical stimulators, rectal electrical stimulators, and bladder wall stimulators is not 
considered reasonable and necessary. Therefore, no program payment may be made for these devices or for 
their implant. 
 
You can find this rule at the Medicare National Coverage Determination (NCD) 230.16: Bladder Stimulators 
(Pacemakers). 
 
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 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 state that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
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 rules say that for outpatient therapy to be considered reasonable and necessary, the services must meet 
Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common. 
In the case of rehabilitative therapy, the patients condition has the potential to improve or is improving in 
response to therapy. A therapy plan of care is developed either by the physician/ non-physician practitioner 
(NPP), or by the physical therapist who will provide the physical therapy services. All services provided are to 
be specific and effective treatments for the patients condition according to accepted standards of medical 
practice; and the amount, frequency, and duration of the services must be reasonable.  The services that are provided must meet the description of skilled therapy. You can find this information in 
Local Coverage Determination (LCD) L33631: Outpatient Physical and Occupational Therapy Services.
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 if a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so 1 Healthcare 
Common Procedure Coding System (HCPCS) code must be submitted for the panel. If the laboratory assays 
genes in serial, then the laboratory must submit claims for genes individually. The order by the treating 
clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the 
patients medical record must reflect that the service billed was reasonable and necessary. In general, 2 or more 
codes describing a genetic test billed on the same beneficiary on the same date may constitute a panel, and if so 
the service must be billed as a single procedural service. You can find this information in Local Coverage 
Article (LCA): Billing and Coding: MolDX: Testing of Multiple Genes (A57880). 
 
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 an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
inpatient only is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
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.