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 79 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 percutaneous transluminal angioplasty (PTA) is covered when used 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) 
Coverage is limited to procedures performed using an FDA-approved CAS, stents and FDA-approved or -
cleared embolic protection devices. 
5. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials 
Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of 
cerebral artery stenosis = 50% in patients with intracranial atherosclerotic disease when furnished in 
accordance with the FDA-approved protocols governing Category B IDE clinical trials. CMS determines that 
coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances. 
 
All other indications for PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral 
arteries remain noncovered. You can find this information in National Coverage Determination (NCD) 
Percutaneous Transluminal Angioplasty (PTA) (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.
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 elective hysterectomy, tubal ligation, and vasectomy, if the primary indication for these 
procedures is sterilization. 
 
You can find this information in the National Coverage Determination (NCD) Sterilization 230.3. 
 
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 state that in contrast to ERFA and laser procedures, intra-operative ultrasound guidance techniques 
have not been shown to increase the effectiveness or safety of sclerotherapy for varicose veins, therefore, intra-
operative ultrasound guidance will not be separately covered for sclerotherapy. 
 
A. Indications for surgical treatment: For example venous ligation, vein stripping and/or sclerotherapy: 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
 
2. The patient is symptomatic and has one, or more, of the following: 
     a. Pain or burning in the extremity severe enough to impair mobility 
     b. Recurrent episodes of superficial phlebitis  
     c. Non-healing skin ulceration  
     d. Bleeding from a varicosity  
     e. Stasis dermatitis  
     f. Refractory dependent edema 
 
B. Indications for ERFA or laser ablation: 
 
In addition to the above (see A), the patient's anatomy and clinical condition are amenable to the proposed 
treatment including ALL of the following: 
 
1. Absence of aneurysm in the target segment. 
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 4. The absence of 
significant peripheral arterial diseases. 
 
You can find this information in the Local Coverage Determination (LCD) Treatment of Varicose Veins of the 
Lower Extremities L34209.  
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 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 page 8 and 9 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 Health Maintenance Organizations (HMOs) may offer a Point of Service (POS) option as a 
mandatory or optional supplemental benefit. The POS benefit provides coverage for some plan-covered 
services outside of the HMOs network. The HMO plan may either require or waive prior authorization rules 
for obtaining POS services. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 the Point of Service (POS) benefit provide coverage of out-of-network services. For 
some services, approval in advance (prior authorization) is required. You can find this information on page 37 
of the Plan's 2023 EOC. 
 
The Plan contract also says prior authorization rules may apply to outpatient diagnostic tests. You can find this 
information on page 61 of the Plan's 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 effective January 18, 2017, the Centers for Medicare & Medicaid Services (CMS) covers 
leadless pacemakers through Coverage with Evidence Development (CED). CMS covers leadless pacemakers 
when procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, 
in prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA approved 
label for devices that have either: 
 
1. an associated ongoing FDA approved post-approval study; or 
2. completed an FDA post-approval study. 
 
You can find this rule in the National Coverage Determination (NCD) - Leadless Pacemakers (20.8.4). 
 
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 claims must specify whether equipment is rented or purchased. For purchased equipment, 
the itemized bill or claim must also indicate whether equipment is new or used. You can find this information 
in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 20, Section 130.9. 
 
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 state that the unit of service (UOS) for the supply allowance (B4034, B4035, or B4036) is one (1) 
UOS per day. Claims that are submitted for more than one UOS per day for HCPCS codes B4034, B4035, or 
B4036 will be rejected. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage 
Article A58833 entitled "Enteral Nutrition- Policy Article." 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. 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. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A56853. 
 
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 the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 30.2.2. 
 
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 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.  
 
The rules say that some International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-
10-CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no 
bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If 
the side is not identified in the medical record, assign the code for the unspecified side. You can find this 
information in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
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 $65 copayment for vision care. You can find this information on pages 
80 to 81 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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
Codes with an MAI of 3 are based on criteria combined with data such that it would be possible, but 
medically unlikely, that higher values would represent correctly reported medically necessary services. To be 
paid, there must be evidence (e.g., medical review) that the excess units were actually provided, were correctly 
coded, and were medically necessary. 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(V). 
 
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). 
 
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 when billing for AAA screenings, the following ICD-10 codes should be billed: 
 
- Z13.6 for the encounter for screening for cardiovascular disorders and either 
 
- The most appropriate code for tobacco usage: Z87.891, F17.210, F17.211, F17.213, F17.218 and F17.219 OR 
 
- Z84.89 for family history of other specified conditions 
 
You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: Once in a Lifetime 
Abdominal Aortic Aneurysm (AAA) Screening Article (A55071). 
 
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 National Coverage Determination (NCD)  Next Generation Sequencing (NGS) 
(90.2)  Effective January 27, 2020. 
 
The rules say that effective for services performed on or after January 27, 2020, CMS has determined that NGS 
as a diagnostic laboratory test is reasonable and necessary and covered nationally for patients with germline 
(inherited) cancer, when performed in a CLIA-certified laboratory, when ordered by a treating physician and 
when all of the following requirements are met: 
a. Patient has: 
i. ovarian or breast cancer; and, 
ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and, 
iii. a risk factor for germline (inherited) breast or ovarian cancer; and 
iv. not been previously tested with the same germline test using NGS for the same germline genetic content.  
b. The diagnostic laboratory test using NGS must have all of the following: 
 
i. FDA-approval or clearance; and, 
ii. 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 National Coverage Determination (NCD)  Next Generation Sequencing (NGS) 
(90.2)  Effective January 27, 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 state that Covered Indications 
 
Thermal destruction of the intraosseous basivertebral nerve (BVN) will be considered medically reasonable and 
necessary for the treatment of chronic low back pain in patients who meet ALL the following criteria:  
 
    -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 
    -Documented failure to respond to greater than or equal to 6 months of non-surgical management, AND 
    -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 
    -Evidence of Type 1 or Type 2 Modic changes on 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. 
 
Patients must have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to 
thermal destruction of the intraosseous BVN (such screening must include psychological, as well as, physical 
evaluation). Documentation of the history and careful screening must be available in the patient chart if 
requested. 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.