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 72 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 whole gland high-intensity focused ultrasound (HIFU) is considered medically necessary as 
a local treatment for recurrent prostate cancer (PCa) following radiation therapy (RT) when all of the following 
criteria are met: 
1. Biochemical recurrence (BCR) according to the Phoenix definition 
2. Positive post-RT transrectal ultrasound guided (TRUS) biopsy 
3. Candidate for local curative therapy as evidenced by favorable clinical and pathologic factors (BOTH 
of the following) 
a. Original (pre-RT)- clinical stage T1-T2, NX or N0 
b. Current (all are required) 
i. Prostate-specific antigen (PSA) less than 10 ng/mL 
ii. Absence of distant metastases per National Comprehensive Cancer Network (NCCN) 
imaging guidelines 
iii. No lymph node involvement 
iv. Interval to biochemical failure greater than 18 months 
v. International Society of Urological Pathology (ISUP) grade less than 4 
vi. Local recurrence amenable to entire destruction 
c. Multi-disciplinary consensus (surgeon, oncologist, radiologist) 
d. Hi comorbidity (i.e., not a candidate for radical prostatectomy (RP)) 
 
You can find these rules in Local Coverage Determination (LCD) Salvage High-Intensity Focused Ultrasound 
(HIFU) Treatment in Prostate Cancer (PCa) (L38262). 
 
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 SelectMDx is a gene expression assay measuring mRNA levels of homeobox C6 (HOXC6) 
and distal-less hemeobox 1 (DLX1) in post-DRE urine; both HOXC6 and DL1 may be involved in the onset of 
prostate cancer and are associated with HGPC (36). A prospective, multicenter study involved a training cohort 
(n=519) and validation cohort (n=386) in men scheduled for prostate biopsy (PSA = 3ng/mL, abnormal DRE, 
or family history of prostate cancer) (37). Using a cut-off of 27.5 for the prediction of HGPC, the expression of 
DLX1 and HOXC6 alone resulted in an AUC of 0.76 and 0.73 for the two cohorts, respectively. Combined 
with other SOC risk factors, the AUC increased to 0.90 in the training set and 0.86 in the validation set. You 
can find this rule in the Local Coverage Determination (LCD): Biomarker Testing for Prostate Cancer 
Diagnosis L37733. 
 
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 MolDX will reimburse approved tests covered for dates of service consistent with the 
effective date of the covered determination. You can find this rule in the Local Coverage Determination (LCD) 
- MolDX: Molecular Diagnostic Tests (MDT) - Effective November 1, 2019. 
 
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 repeat epidural steroid injection (ESI) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using SAME scale* for at least three months.7,8 If a patient fails to 
respond well to the initial ESI, a repeat ESI after 14 days can be performed using a different approach, level 
and/or medication, if appropriate, with the rationale and medical necessity for the second ESI documented in 
the medical record. You can find this information in Local Coverage Determination (LCD): Epidural Steroid 
Injection for Pain Management (L33906). 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that providers performing validity testing on urine specimens utilized for drug testing should not 
separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, 
creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not 
separately billed. You can find this information in the National Correct Coding Initiative (NCCI) Policy 
Manual, Chapter X, page X-7. 
 
The rules say that modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community-based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 you can choose to receive care from out-of-network providers. Our plan will cover services 
from either in-network or out-of-network providers, as long as the services are covered benefits and medically 
necessary. However, if you use an out-of-network provider, your share of the costs for your covered services 
may be higher. You can find this information on page 9 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 that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report CPT code 81479 
(Unlisted molecular pathology procedure) with one unit of service. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) 
Manual, Chapter 10, Section F(8). 
 
The rules say that Pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
    1. 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; AND 
 
    2. The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-
reviewed process and determined to demonstrate actionability in clinical decision making by CPIC guideline 
level A or B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label. 
 
Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, 
the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing 
CMS national coverage determinations, and all Medicare payment rules. 
 
You can find this rule in the Local Coverage Determination (LCD) Pharmacogenomics Testing L39073. 
 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 $50 per day, for days 1 through 5 and $0 per day, for days 6 through 90 
for inpatient mental health care. You can find this information on page 92 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 that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
 
The rules state that under the home health prospective payment system (HH PPS), before January 1, 2020, a 
case-mix adjusted payment for a 60-day episode is made using one of 153 Home Health Resource Groups 
(HHRGs). After January 1, 2020, under the Patient-Driven Payment Model, a case-mix adjusted payment for a 
30-day period of care is made using one of 432 HHRGs. On Medicare claims, these HHRGs are represented as 
Health Insurance Prospective Payment System (HIPPS) codes. You can find this information in the Medicare 
Claims Processing Manual, Chapter 10, Section 10.1.8. 
 
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 say that Section 424.57(c)(12) requires suppliers, as part of their standards to be met for enrollment 
and participating, to maintain proof of delivery documentation in their files. In certain instances, compliance 
with proof of delivery may be required as a condition of payment, and must be available. For such items, if the 
supplier does not have appropriate proof of delivery documentation within the prescribed timeframes, 
associated claims will be denied, and overpayments recouped. You can find this rule in the Medicare Program 
Integrity Manual, Chapter 5, Section 5.8. 
 
The rules say that claims for pneumatic compression devices that do not meet the face-to-face encounter will be 
denied as not reasonable and necessary. You can find this rule in the Local Coverage Article (LCA) - 
Pneumatic Compression Devices - Policy Article (A52488) - Effective January 1, 2020. 
 
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 tests evaluated through the application process and/or technical assessment will be reviewed 
to answer the following questions: 
 
1. Is the test performed in the absence of clinical signs and symptoms of disease? 
2. Will the test results provide the clinician with information that will improve patient outcomes and/or change 
physician care and treatment of the patient? 
3. Will the test results confirm a diagnosis or known information? 
4. Is the test performed to determine risk for developing a disease or condition? 
5. Will risk assessment change management of the patient? 
6. Is there a diagnosis specific indication to perform the test? 
7. Is the test performed to measure the quality of a process or for Quality Control/Quality Assurance (QC/QA), 
i.e., a test to ensure a tissue specimen matches the patient? 
 
You can find this rule in the Local Coverage Determination (LCD) - MolDX: Molecular Diagnostic Tests 
(MDT) (L36807) - Effective December 30, 2021. 
 
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 Negative Pressure Wound Therapy (NPWT) is defined as the application of sub-atmospheric 
pressure to a wound to remove exudate and debris from wounds. NPWT is delivered through an integrated 
system of a suction pump, separate exudate collection chamber and dressing sets to a qualified wound. In these 
systems, exudate is completely removed from the wound site to the collection chamber. This rule can be found 
in the Local Coverage Determination (LCD) Negative Pressure Wound Therapy Pumps L33821. 
 
The rules say that codes 97602, 97605, 97606, 97607 and 97608 include the application of and the removal of 
any protective or bulk dressings. However, if only a dressing change is performed without any active wound 
procedure as described by these debridement codes, these debridement codes should not be reported. This rule 
can be found in the Local Coverage Article: Billing and Coding: Wound Care A55818. 
 
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 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 for outpatient diagnostic services, including lab services, your provider may need to 
get prior authorization. You can see this starting on page 4-47 of the Plans 2021 Evidence of Coverage.