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 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 Medicare will consider invasive procedures, such as a slab phlebectomy, as reasonable and 
necessary when documentation in the medical record includes a history, physical examination, Clinical-
Etiology-Anatomy-Pathophysiology (CEAP) clinical classification, and a venous duplex scan documenting 
reflux (greater than 500 milliseconds). 
 
Saphenous veins management with surgery is considered reasonable and necessary with documentation in the 
medical record of CEAP class C2-C6 disease, reflux, and ANY of the following signs or symptoms:  
 
a. Ulceration secondary to venous stasis, 
b. Significant pain or significant edema associated with saphenous reflux that interferes with activities of daily 
living (ADLs), 
c. Bleeding associated with ruptured superficial varicosity, 
d. Recurrent episodes of superficial phlebitis, 
e. Stasis dermatitis, 
f. Refractory dependent edema 
 
You can find this information in the Local Coverage Determination (LCD): Treatment of Varicose Veins of the 
Lower Extremities (L39121). 
 
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 topical hyperbaric oxygen chambers (A4575) will be denied as not reasonable and 
necessary. You can find this rule in the Local Coverage Determination for Oxygen and Oxygen Equipment, 
L33797. 
 
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 & 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 107 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 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 PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
 
1. Inclusion criteria (ALL are required): 
 
1. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on symptom onset, and 
documented by advanced imaging 
2. Symptomatic (ONE): 
-Hospitalized with severe pain 
-Non-hospitalized with moderate to severe pain despite optimal non-surgical management (ONE): 
 -Worsening pain 
 -Stable to improved pain: 
  Progression of vertebral body height loss 
  > 25% vertebral body height reduction 
  Kyphotic deformity 
  Severe impact of VCF on daily functioning 
3. Continuum of care (Both) 
 -All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education 
for subsequent treatment as indicated. 
 -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): 
 
1. Absolute contraindication 
 -Current back pain is not primarily due to the identified acute or subacute VCF(s). 
 -Osteomyelitis, discitis or active systemic or surgical site infection 
 -Pregnancy 
2. Relative contraindication 
 -Greater than three vertebral fractures per procedure 
 -Allergy to bone cement or opacification agents 
 -Uncorrected Coagulopathy  -Spinal instability 
 -Myelopathy from the fracture 
 -Neurologic deficit 
 -Neural impingement 
 -Fracture retropulsion/canal compromise 
 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34228). 
 
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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 160. 
 
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 $340 copayment for each covered visit to an ambulatory surgical center or 
outpatient hospital facility. You can find this information in Chapter 4 on page 81 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. 
 
  
  
  Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 
50.4.1 and 50.4.2. 
 
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 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 33 of the Plan's 2023 and 
2024 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 a pneumatic compression device (PCD) coded as E0652 is not covered for the treatment of 
lymphedema of the extremities alone. A PCD coded as E0652, is covered for the treatment of lymphedema 
  
  extending onto the chest, trunk and/or abdomen when all of the following are met: 
 
1. The beneficiary has lymphedema of an extremity as defined above 
  
2. The coverage criteria for an E0650 or E0651 are met 
  
3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits 
of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve 
with a four-week trial. 
  
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
  
The rules say that the only time that a segmented, calibrated gradient pneumatic compression device (HCPCS 
code E0652) would be covered is when the individual has unique characteristics that prevent them from 
receiving satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a 
segmented appliance or a segmented compression device without manual control of pressure in each chamber. 
  
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
  
The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment with and 
E0650 or E0651 is required for coverage of E0652. You can find this rule in Local Coverage Determination 
(LCD): Pneumatic Compression Devices (L33829) - Effective January 1, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say facet joint interventions are considered medically reasonable and necessary for the diagnosis and 
treatment of chronic pain in patients who meet all the following criteria: 
 
1.    Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale. 
 
2.    Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated). 
 
3.    Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst). 
 
4.    There is no non-facet 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. 
 
You can find this rule in the Local Coverage Determination (LCD) L35936: Facet Joint Interventions 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 Molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when ALL of the following are true: 
 
   1. The patient has a personal history of melanoma AND: 
       a. Either: 
           i. Has Stage T1b and above OR 
           ii. Has T1a with documented concern about adequacy of microstaging 
       b. Is undergoing workup or being evaluated for treatment, AND 
       c. Does not have metastatic disease AND 
       d. Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or 
other information is >5% AND 
       e. Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended 
use of the test 
   2, The TEST has demonstrated, as part of a Technical Assessment: 
       a. Clinical validity of analytes tested in predicting metastatic disease (or the absence of metastatic disease) 
in peer-reviewed scientific literature 
       b. Utility beyond clinical, histological, and radiographical factors in the ability to accurately stratify 
patients into risk groups to manage patient care, such by precluding unnecessary sentinel lymph node biopsies 
       c. Appropriate analytical validity 
       d. Performance characteristics equivalent or superior to other covered, similar tests. 
 
You can find this rule in the Local Coverage Determination (LCD) for MolDX: Melanoma Risk Stratification 
Molecular Testing (L37725). 
 
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). 
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 January 9, 2014, posterior image-guided lumbar 
decompression (PILD) will be covered by Medicare through Coverage with Evidence Development (CED) for 
beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an approved clinical study that meets the 
following criteria. Centers for Medicare and Medicaid Services (CMS) has a particular interest in improved 
beneficiary function and quality of life, specific characteristics that identify patients who may benefit from the 
procedure, and the duration of benefit. A clinical study seeking Medicare payment for PILD for LSS must 
address one or more aspects of the following questions in a prospective, randomized, controlled design using 
current validated and reliable measurement instruments and clinically appropriate comparator treatments, 
including appropriate medical or surgical interventions or a sham controlled arm, for patients randomized to the 
non-PILD group. 
 
The study protocol must specify a statistical analysis and a minimum length of patient follow up time that 
evaluates the effect of beneficiary characteristics on patient health outcomes as well as the duration of benefit. 
 
These studies must be designed so that the contribution of treatments in addition to the procedure under study 
are either controlled for or analyzed in such a way as to determine their impact. 
 
The prospective, longitudinal study must also meet the following criteria: 
 
The protocol must specify a statistical analysis and a minimum length of patient follow-up time that evaluates 
the effect of beneficiary characteristics on patient health outcomes as well as the duration of the benefit. 
The eligibility requirements, both inclusion and exclusion criteria that were specified in the CMS-approved 
RCT protocol, must be maintained in the new prospective, longitudinal study. 
All study sites and study results must be listed in the ClinicalTrials.gov database. 
 
You can find this information in the National Coverage Determination (NCD) Percutaneous Image-Guided 
Lumbar Decompression for Lumbar Spinal Stenosis 150.13. 
 
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 vacuum erection devices (L7900) and related supplies are considered Prosthetic Devices 
under the Prosthetic Devices benefit category (Social Security Act 1861(s)(8)). For dates of service on or after 
July 1, 2015, codes L7900 and L7902 are statutorily non-covered based on the Achieving a Better Life 
Experience (ABLE) Act of 2014 (see Social Security Act 1834(a)(1)(I)). You can find these rules in the Local 
Coverage Article Vacuum Erection Devices (VED) - Policy Article A52712. 
 
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.