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 a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and 
necessary. You can find this information in the ocal Coverage Determination (LCD) Cold Therapy L33735. 
 
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 63 of the Plans 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 state that when it is medically necessary for a patient to receive detoxification and/or rehabilitation 
for drug substance abuse as a hospital inpatient, coverage for care in that setting is available. Coverage is also 
available for treatment services that are provided in the outpatient department of a hospital to patients who, for 
example, have been discharged from an inpatient stay for the treatment of drug substance abuse or who require 
treatment but do not require the availability and intensity of services found only in the inpatient hospital 
setting. The coverage available for these services is subject to the same rules generally applicable to the 
coverage of outpatient hospital services. Decisions regarding reasonableness and necessity of treatment, the 
need for an inpatient hospital level of care and length of treatment, should be made by contractors based on 
accepted medical practice with the advice of their medical consultant. You can find these rules in National 
Coverage Determination (NCD) Treatment of Drug Abuse (Chemical Dependency) (130.6). 
 
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 must make services geographically accessible and consistent with local community 
patterns of care. Commonly used services should be available within a reasonable distance and travel time. 
Longer distances and travel times are permissible when they are based on location (such as a rural area) and/or 
established and based on routine patterns of care. 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 110.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services provided at the in-network benefit level. 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 at the in-network benefit 
level. You can find this information on page 9 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 64 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 respiratory panels will only be covered when targeted testing is not appropriate. The test 
panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A 
panel cannot be unbundled and billed as individual components regardless of the fact that the test reports 
multiple individual pathogens and/or targets. You can find this rule in the Local Coverage Determination and 
Article for Molecular Diagnostics (MolDX): Molecular Syndromic Panels for Infectious Disease Pathogen 
Identification Testing, L38988 and A58710. 
 
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 not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not include 
coverage for dental service codes D6241 and D6751. You can find this information in Chapter 4 on pages 47-
49 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for over the counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2.  
 
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 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 up to 24 one-way trips to Plan approved locations every year. You can find this information on page 82 
of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that 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 supporting one of 
the following: 
2) Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis; or 
3) Post-laminectomy syndrome; or 
Acute herpes zoster associated pain and 
4) 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. and 
5) 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 the Local Coverage Determination (LCD) L39242: Epidural Steroid Injections 
for Pain Management: 
 
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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with both of the following: 
1. Inclusion criteria (all are required): 
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture 
(VCF) (T1  L5), based on symptom onset, and documented by advanced imaging 
b. Symptomatic (one of the following): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score of 8 or more) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite 
optimal non-surgical management (NSM) (one of the following): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still of 5 or more) (with 2 or more of 
the following): 
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (Both) 
i. All patients presenting with VCF should be referred for evaluation of bone mineral 
density (BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have none of the following):   
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy b. Relative contraindication 
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
intraoral  comprehensive series of radiographic images but is limited to1 procedure code per calendar year. 
This benefit also includes coverage for specifically listed dental services. Gingival irrigation with a medicinal 
agent  per quadrant is not listed as covered. You can find this information on pages 74-77 of the Plan's 2023 
Evidence of Coverage (EOC).   
 The Plan contract says that enrollees must pay a $25 copayment for periodontal scaling and root planing - four 
or more teeth per quadrant (D4341), and periodontal scaling and root planing  one to three per quadrant 
(D4342) provided in-network. You can find this information on page 75 of the Plans 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 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 also say that modifier -24 reports an unrelated evaluation and management service by same physician 
during a postoperative period. The physician may need to indicate that an evaluation and management service 
was performed during the postoperative period of an unrelated procedure. This circumstance is reported by 
adding the modifier -24 to the appropriate level of evaluation and management service. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 40.2.7. 
 
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 sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when 
all the following requirements are met: 
1. Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
between the upper level of the iliac crests and the gluteal fold, AND 
2. Low back pain duration of at least three (3) months, AND 
3. Low back pain below L5 without radiculopathy, AND 
4. Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal 
stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, 
pseudoarthrosis, or pain related to spinal instrumentation), AND 
5. At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or 
Posterior Shear, SI Compression, SI Distraction and Yeoman Tests, AND 
6. Low back pain persists despite a minimum of four weeks of conservative therapies. 
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.