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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
  
   
 The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 Other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been 
tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 160.7. 
 
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 Right heart catheterization is indicated to evaluate: 
1. Valvular heart disease; 
2. Congestive heart failure; 
3. Congenital heart disease; 
4. Cor pulmonale; 
5. Pulmonary hypertension; 
6. Intracardiac shunts (including septal rupture) and extracardiac vascular shunts; 
7. Suspected cardiomyopathy or myocarditis; 
8. Endocarditis anticipated to require valvular surgical repair; 
9. Suspected rejection of a transplanted heart; 
10. Suspected pericardial tamponade or constriction. 
 
You can find this rule in Local Coverage Determination (LCD) Cardiac Catheterization and Coronary 
Angiography L33557. 
 
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 thermal destruction of the intraosseous basivertebral nerve (BVN) will be considered 
medically reasonable and necessary for the treatment of chronic low-back pain (cLBP) in patients who meet 
ALL the following criteria: 
 
1. Chronic lumbar back pain of greater than or equal to 6 months duration that causes functional deficit 
measured on a pain or disability scale, AND 
2. Documented failure to respond to greater than or equal t 6 months of non-surgical management, AND 
3. Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity, 
AND 
4. Evidence of Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI), such as 
inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous 
tissues within the adjacent marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral 
body marrow including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic 
change), in 1 or more vertebrae from L3-S1. 
 
You can find this information in the Local Coverage Determination (LCD): Thermal Destruction of the 
Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420). 
 
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 epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following three (3) requirements are met: 
1. History, physical examination, and concordant radiological image-based diagnostic testing and 
supporting one of the following: 
- Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis; or 
- Post-laminectomy syndrome 
- Acute herpes zoster associated pain 
2. Radiculopathy, Radicular pain and/or neurogenic claudication is severe enough to greatly impact 
quality of life or function. An objective pain scale or functional assessment must be performed at 
baseline (prior to interventions). The same scale must be repeated at each follow-up for assessment of 
response. 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute 
herpes zoster refractory to conservative management where a four (4) week wait is not required. 
 
You can find this information in Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L39242). 
 
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 will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. 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 110.1(C). 
 
The rules say that HCPCS code K0738 describes a feature of an oxygen concentrator that allows the 
beneficiary to fill portable gaseous oxygen cylinders from a stationary concentrator. This feature may be 
integrated into the stationary concentrator or be a separate component. When code K0738 is billed, code E0431 
(portable gaseous oxygen system, rental) must not be used. You can find this rule in the Local Coverage Article 
Oxygen and Oxygen Equipment - Policy Article A52514. 
 
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 claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other supplier claims is a claim that exactly matches another claim or claim line with respect to, among other items, provider number, date of service, procedure code, place of services, and billed amount. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 120.2.. 
 
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 RFA of the SI joint is not considered reasonable and necessary. You can find this in the 
Local Coverage Determination (LCD): Sacroiliac Joint Injections and Procedures (L39462). 
 
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:  
o Implantable (or Insertable Loop) Recorder (ILR) 
Another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left chest and 
may remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related 
but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
You can find this rule at the Medicare National Coverage Determination (NCD) 20.15: Electrocardiographic 
Services. 
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 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 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. If additional organisms are not included in a 
panel, testing for those organisms separately may be reasonable and necessary when ordered in addition to the 
panel and supported by documentation in the medical record. You can find this rule in the Local Coverage 
Article (LCA) for Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen 
Identification Testing (A58747). 
 
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 each Medicare-covered CT scan. You can find this 
information on page 95 of the Plan's 2022 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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet all the 
following criteria: 
a. Initial thermal radiofrequency ablation (RFA): 
- After the patient has had at least two (2) medically reasonable and necessary diagnostic medical 
branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain (with the duration of relief being consistent with the agent used) and 
- Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and 
necessary provided the patient had a minimum of consistent 50% improvement in pain for at least 
six (6) months or at least 50% consistent improvement in the ability to perform previously painful 
movements and activities of daily living (ADLs) as compared to baseline measurement using the 
same scale 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L35936). 
 
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 all the following must be present for coverage eligibility: 
1. The patient must have 
a. Any cancer diagnosis 
b. AND a clinical indication for germline (inherited) testing for hereditary cancer 
c. AND a risk factor for germline (inherited) cancer 
d. AND has not been previously tested with the same germline genetic content. 
2. The test has satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services 
Program (MolDX) for the stated indications of the test. 
3. The test performed includes at least the minimum genetic content (genes or genetic variants) with definitive 
or well-established guidelines-based evidence required for clinical decision making for its intended use that 
can be reasonably detected by the test. 
a. 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. 
b. A single gene or variant may be tested if it is the only gene or variant considered to be reasonable 
and necessary for a cancer type. 
4. If a previous test was performed with a similar/duplicative intended use, a subsequent test is only 
reasonable and necessary if the non-duplicative genetic content of the second test is reasonable and 
necessary. 
5. If the test is an NGS test, it must abide by all conditions listed in the NCD 90.2. 
 
You can find this rule in the Local Coverage Determination (LCD) for MolDX: Lab-Developed Tests for 
Inherited Cancer Syndromes in Patients with Cancer, L38972. 
 
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 state that for services that contain both a technical component and a professional component, the 
technical component, if any, must be billed by the skilled nursing facility (SNF) for its Part A inpatients. The 
A/B Medicare Administrative Contractor (MAC) (B) will pay only the professional component to the 
physician. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Claims Processing Manual, Chapter 6, Section 20.1.1. 
 
The rules say that, as a result of SNF Consolidated Billing (Section 4432(b) of the Balanced Budget Act (BBA) 
of 1997), carriers may not pay for the technical component of radiology services furnished to SNF inpatients 
during a Part A covered stay. The SNF must bill radiology services furnished its inpatients in a Part A covered 
stay and payment is included in the SNF Prospective Payment System (PPS). You can find this information in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 13, Section 20.2.1. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 covered therapeutic continuous glucose monitors are limited to Freestyle Libre products 
manufactured by Abbott. You can find this information on pages 68-69 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 PTA is covered under the following conditions: 
 
1. Treatment of Atherosclerotic Obstructive Lesions 
2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA)-Approved Category B 
Investigational Device Exemption (IDE) Clinical Trials 
3. Concurrent with Carotid Stent Placement in FDA-Approved Post Approval Studies 
4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 20.7. 
 
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.