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 page 123 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 Codes L5000, L5010, and L5020 describe products that are necessary for standing balance 
and toe off support in beneficiaries who are missing the forefoot or digits including the hallux (great toe) and 
  
  who require the rigidity and support offered by these products, in order to achieve or maintain an effective gait. 
 
L5000 describes a shoe insert with a rigid longitudinal arch support that also incorporates material 
accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact 
is made with the residual limb or toes. These inserts are designed to provide standing balance and toe off 
support for improved gait. L5000 is inclusive of variations in materials or combinations such as differing 
stiffnesses or Shore value. You can find this information in Medicare's Local Coverage Article: Lower Limb 
Prostheses - Policy Article (A52496). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 page(s) 42-45 of the Plan's 
2021 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 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. While the Plan offers a Point-of-Service option for coverage of 
out-of-network services, this benefit does not apply to specialist visits. You can find this information on pages 
43 and 121 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 state that effective for dates of service specified below, the Centers for Medicare & Medicaid 
Services (CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under 
section 1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development 
(CED) for beneficiaries with LSS who are enrolled in an approved clinical study that meets the criteria in 
section I or II below: 
 
Effective for services performed on or after January 9, 2014, PILD will be covered by Medicare through CED 
for beneficiaries with LSS who are enrolled in an approved clinical study that meets the following criteria. 
CMS has a particular interest in improved beneficiary function and quality of life, specific characteristics that 
identify patients who may benefit from the procedure, and the duration of benefit. A clinical study seeking 
Medicare payment for PILD for LSS must address one or more aspects of the following questions in a 
prospective, randomized, controlled design using current validated and reliable measurement instruments and 
clinically appropriate comparator treatments, including appropriate medical or surgical interventions or a sham 
controlled arm, for patients randomized to the non-PILD group. 
The study protocol must specify a statistical analysis and a minimum length of patient follow up time that 
evaluates the effect of beneficiary characteristics on patient health outcomes as well as the duration of benefit. 
 
You can find this information in the National Coverage Determination (NCD) Percutaneous Image-Guided 
Lumbar Decompression for Lumbar Spinal Stenosis 150.13. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. Covered dental services are 
listed on pages 126-128 in the Pan's 2023 Evidence of Coverage. Any service not listed is not covered.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 that chiropractic providers are required to bill their services using the AT Modifier to indicate 
active treatment.  You can find this rule at Centers for Medicare and Medicaid Services, MedLearn Matters 
Bulletin SE1602. 
 
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 a type 1 Excludes note on a diagnosis code is a pure excludes note. It means NOT CODED 
HERE! An Excludes1 note indicates that the code excluded should never be used at the same time as the code 
above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a 
congenital form versus an acquired form of the same condition. You can find this information in the 
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines 
for Coding and Reporting, Section I.A.12.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 state that payment is not made under the physician fee schedule for the technical component (TC) of 
services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., 
hospital inpatient and outpatient settings. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
12, Section 60. 
 
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 diagnosis codes with an Excludes1 note indicates that the diagnosis code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
You can find this rule at Centers for Medicare and Medicaid Services, ICD-10-CM Official Guidelines for 
Coding and Reporting, Section I.12. 
 
 
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. While the Plan offers a Point-of-Service option for coverage of 
out-of-network services, this benefit only applies to dental services. You can find this information on page 32 
to 33 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 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. You can find this information  
on pages 82-86 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 state that diagnosis codes with an Excludes1 note indicates that the diagnosis code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
You can find this rule at Centers for Medicare and Medicaid Services, ICD-10-CM Official Guidelines for 
Coding and Reporting, Section I.12. 
 
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 can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
You can find this rule at 42 CFR Section 422.113(c). 
 
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 1-6 of the 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 the Medicare approved amount for surgical procedures includes payment for the intra-
operative services and supplies related to the surgery when furnished by the physician who performs the 
surgery. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
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.
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 test panel is a single test with multiple components and is characterized by a single unit 
of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact 
that the test reports multiple individual pathogens and/or targets. You can find this rule at Local Coverage 
Article (LCA) A52786: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification 
Testing (eff. 4/17/22). 
 
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 more than one spring powered device (code A4258) per 6 months is not reasonable and 
necessary. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage 
Determination L33822 entitled "Glucose Monitors." 
 
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 Molecular Diagnostic Services Program (MolDX) will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. You can find this rule in Local Coverage Determination 
(LCD): MolDX: Molecular Diagnostic Tests (MDT) (L36256). 
 
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 say that under Group 3 paragraph, Tier 1 non-covered codes, Genetic testing procedures submitted 
under the following CPT codes are unlikely to impact therapeutic decision-making in the clinical management 
of the patient and will be denied automatically as not medically necessary: 81460. You can find this rule in 
Local Coverage Article Billing and Coding: Molecular Pathology Procedures A56199. 
 
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.