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 state that clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
- Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance 
and a prosthesis does not enhance their quality of life or mobility. 
- Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at 
fixed cadence. Typical of the limited and unlimited household ambulator. 
- Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental 
barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
- Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community 
ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
- Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, 
exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active 
adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic 
response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or 
shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 
or above. An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional 
level is 2 or above. You can find these rules in Local Coverage Determination (LCD) Lower Limb Prosthesis 
(L33787). 
 
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. 
 
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 health 
Plan contract says that urgently needed services are provided to treat a non-emergency, unforeseen medical 
illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished 
by network providers or out of network providers when network providers are temporarily unavailable or 
inaccessible. You are covered for urgently needed care worldwide. You can find this information on page 102 
of the Plans 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 vascular surgical treatment is indicated when: 
 
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 
 
You can find this rule at Local Coverage Determination (LCD) L34209: Treatment of Varicose Veins of the 
Lower Extremities (eff. 12/1/19). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that there is insufficient evidence in the published peer-reviewed scientific literature to support 
coverage for genetic testing for inherited thrombophilias outside the pregnant women as described above. 
Genetic testing for FVL and F2 G20210A is considered investigational for all other indications. However, 
Medicare may consider coverage for FVL and/or F2 genetic testing in unusual circumstances where testing will 
change clinical management of the patient. 
 
You can find this information in the Local Coverage Determination (LCD) MolDX: Genetic Testing for 
Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (L36400). 
 
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 contractors pay for initial observation care billed by only the physician who ordered 
hospital outpatient observation services and was responsible for the patient during his/her observation care. 
When a patient is admitted for observation care and then is discharged on a different calendar date, the 
physician shall report Initial Observation Care, from CPT code range 99218  99220, and CPT observation 
care discharge CPT code 99217. 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 
30.6.8. 
 
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. 
 
Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis 
and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint 
dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless 
conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. 
 
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. 
Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by 
the intra-articular injection of a small volume of local anesthetics of different durations of actions. A positive 
response should demonstrate initial pain relief greater than or equal to (greater than or equal to) 75% - 100% 
and the ability to perform previously painful maneuvers. Steroids may be injected in addition to the local 
anesthetic. 
 
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and 
potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that 
the SI joint is the source of pain in the lower back. The local anesthetic used for the procedure should not be 
billed. 
 
SI joint arthrography and/or therapeutic injection of an anesthetic/steroid should only be reported when 
imaging confirmation of intra-articular needle positioning with applicable radiological and/or fluoroscopic 
procedures have been performed. 
 
Limitations for Sacroiliac (SI) Joint Injections: 
 
If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for 
immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections 
would not be considered medically necessary. 
 
Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. 
 
You can find this rule in the Local Coverage Determination (LCD): Pain Management (L33622). 
 
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 patients medical records must establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patients condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or  
 
2. The patients condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, National Coverage Determinations Manual, Section 280.7(A). 
 
In order to qualify for a semi-electric hospital bed, the patients condition must require frequent change in body 
position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) 
and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last 
requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 280.7(D). 
 
The rules say that a patient lift is covered if transfer between bed and a chair, wheelchair, or commode is 
required and, without the use of a lift, the beneficiary would be bed confined. 
You can find these rules in the Local Coverage Determination (LCD) for Patient Lifts, L33799. 
 
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 an initial dispensing fee (G0333) is payable to a pharmacy for the initial 30-day supply of 
covered inhalation drug(s) regardless of the number of drugs dispensed, the number of shipments, or the 
number of pharmacies used by the beneficiary during that time. This initial 30-day dispensing fee is a once in a 
lifetime fee and only applies to beneficiaries who are using inhalation drugs for the first time as a Medicare 
beneficiary on or after 01/01/2006. If code G0333 is billed for a 30-day supply of covered inhalation drugs and 
it is not the initial 30-day supply (i.e., G0333 has already been billed to Medicare for that beneficiary), the 
claim will be denied as incorrect coding. When code G0333 has been billed once in a beneficiarys lifetime, 
subsequent claims for a 30-day dispensing fee must be billed using code Q0513. You can find this information 
in the Local Coverage Article (LCA): Nebulizers - Policy Article (A52466). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 113 to 114 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 a spinal cord stimulator is covered to treat intractable pain caused by nerve root injuries, 
post-surgical or post-traumatic including that of post-laminectomy syndrome (failed back syndrome). This rule 
  
  is found in Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal Column Stimulation) 
(L35450). 
 
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 the following conditions are met (42 CFR 422.100(l)): 
 
    1. The MA plan provides all categories of DME covered under original Medicare Part B; 
 
    2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 
    3. The MA plans contracted suppliers provide access to all preferred DME brands; 
 
    4. During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide 
a 90-day transition period (commencing with the initial time of enrollment) during which the plan provides 
(and repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 
    5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 
    6. The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 
    7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-
preferred DME product or brand with the evidence of coverage (EOC) and (annual notice of change) ANOC 
and on its website; and 
 
    8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or   
subcategories annually determined by CMS to require full coverage. 
 
You can find this information at Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 
Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary Protections 10.12.2- Specifying Brands 
or Manufacturers of Durable Medical Equipment (DME). 
 
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 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 (1,2): 
 
1. Biochemical recurrence (BCR) according to the Phoenix definition (PSA nadir + 2 ng/mL) 
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 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 over 18 months 
v. International Society of Urological Pathology (ISUP) grade less than 4 
vi. local recurrence amenable to entire destruction 
 
4. Multi-disciplinary consensus (surgeon, oncologist, radiologist) 
5. Hi comorbidity (i.e., not a candidate for radical prostatectomy (RP)) 
 
You can find this rule in the Local Coverage Determination (LCD) - Salvage High-Intensity Focused 
Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262) - Effective April 1, 2020. 
 
The rules say that the exclusion criteria for these services are (NONE of the below are allowed) 
 
1. Life expectancy less than ten years 
2. PCa subtype other than adenocarcinoma 
3. Post radiation therapy androgren deprivation therapy (ADT) 
4. Post radiation therapy anal/rectal stenosis or rectal wall thickness more than 6mm by TRUS or magnetic 
resonance imaging (MRI) 
 You can find this rule in the Local Coverage Determination (LCD) - Salvage High-Intensity Focused 
Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262) - Effective April 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, 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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers a $0 copayment for up to 30 one-way transportation trips to plan-approved locations every year. You 
can find this information on pages 60 to 61 of the Plans 2022 Evidence of Coverage (EOC).