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 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 under Section 1862(a)(2) of the Social Security Act ("the Act"), the Medicare program does 
not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or 
organization has a legal obligation to provide or pay for that service. Also, under Section 1862(a)(3) of the Act, 
if services are paid for directly or indirectly by a governmental entity, Medicare does not pay for the services.  
 
The regulation at 42 CFR 411.4(b) states: "Individuals who are in custody include, but are not limited to, 
individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised 
release, on medical furlough, required to reside in mental health facilities, required to reside in halfway houses, 
required to live under home detention, or confined completely or partially in any way under a penal statute or 
rule." 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 1, Section 10.4. 
 
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 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 
surgical extractions. You can find this information on page 52 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a benefit and are not covered. Similarly, the costs of 
tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly effects the 
management of the patient may not be reimbursed. You can find this rule in the Local Coverage Determination 
for Molecular Pathology Procedures, L34519. 
 
The rules say that pharmacogenetics testing will be considered medically reasonable and necessary if the 
patient has a condition where clinical evaluation has determined the need for a medication that has a known 
gene-drug interaction(s) for which the test results would directly impact the drug management of the patients 
condition; and the test meets evidence standards for genetic testing as evaluated by a scientific, transparent, 
peer-reviewed process and determined to demonstrate actionability in clinical decision making. You can find 
this rule in the Local Coverage Determination for Pharmacogenomics Testing, L39073. 
 
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 includes specific 
dental procedures included in a dental benefits chart. Core buildup (D2950) is not listed as a covered dental 
benefit. You can find this information on pages 73-75 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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that only the preferred brand products listed in the EOC are covered. You can find this 
information in Chapter 4 on page 59 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 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 facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of 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
11
; AND* 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management (as tolerated)
4,12
; AND 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused 
by facet joint synovial cyst)
4,7
; AND 
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.
11
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L34892). 
 
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 only certain diagnosis codes support medical necessity for code 81270. All other codes not 
listed do not support medical necessity. You can find this rule in the Local Coverage Article (LCA) for Billing 
and Coding: Biomarkers for Oncology (A52986). 
 
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 60-61 in 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 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. 
 
Thermal destruction of the intraosseous BVN will be considered medically reasonable and necessary for the 
treatment of cLBP in patients who meet ALL the following criteria: 
1. Chronic lumbar back pain of 6 months duration that causes functional deficit measured on a pain or 
disability scale*, AND 
2. Documented failure to respond to 6 months of non-surgical management**, AND 
3. Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity, AND 
4. Evidence of Type 1 or Type 2 Modic changes on 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. 
* Pain assessment and a disability scale must be obtained at baseline to be used for functional assessment. 
 ** Non-surgical management may include but is not limited to: 
 Avoidance of activities that aggravate pain; 
 Trial of Chiropractic manipulation; 
 Trial of Physical Therapy; 
 Cognitive support and recovery reassurance; 
 Injection therapy  epidural and/or facet; 
 Spine biomechanics education; 
 Specific lumbar exercise program; 
 Home use of heat/cold modalities; 
 Low impact aerobic exercise as tolerated; 
 Pharmacotherapy (e.g., non-narcotic analgesics, NSAIDs, muscle relaxants, neuroleptics, and 
narcotics). 
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. 
Local Coverage Determination (LCD): Thermal Destruction of the Intraosseous Basivertebral Nerve 
(BVN) for Vertebrogenic Lower Back Pain (L39420). 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that providers/suppliers must report services correctly. Procedures should be reported with the
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual
for Medicare Services, Chapter I(A).

The rules say that a timely-filed NOA is submitted to and accepted by the A/B MAC (HHH) within five
calendar days after admission date. In instances where an NOA is not timely-filed, Medicare shall reduce the
payment for a period of care, including outlier payment, by the number of days from the home health
admission date to the date the NOA is submitted to, and accepted by, the A/B MAC (HHH), divided by 30.
This reduction shall be a provider liability, and the provider shall not bill the beneficiary for it. Medicare
Claims Processing Manual Chapter 10, Home Health Agency Billing, 10.1.10.3, Submission of the Notice of
Admission (NOA).

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.

Medicare does not pay for acupuncture as an anesthetic, as an analgesic, or for other therapeutic purposes. You
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 30.3, 30.3.1, and 30.3.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that supplemental (extra) coverage is provided for acupuncture. This benefit includes
coverage for routine acupuncture services (limited to 6 visits whether done in-or-out-of-network) for other
conditions, such as: headaches, anxiety, sleep issues, osteoarthritis, chemotherapy side effects and respiratory
disorders. You can find this information on page 69 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.

Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form, or technological features of the device.
This rule does not apply to:

1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.

You can find this rule at 42 CFR Section 411.15(b).

Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42
CFR Section 411.15(c).

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 we cover one routine vision (eye) examination and up to two refractions annually. This
service is not covered out-of-network. You can find this information on page 119 of the 2022 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 only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is
statutorily non-covered. You can find this information in the Local Coverage Article (LCA): Oxygen and
Oxygen Equipment (A52514).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that it is important to know which providers are part of our network because, with limited
exceptions, while you are a member of our plan you must use network providers to get your medical care and
services. The only exceptions are emergencies, urgently needed services when the network is not available
(generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes
use of out-of-network providers. You can see this on page 10 of the Plans 2022 Evidence of Coverage.

The Plan contract says that in Original Medicare, people who rent certain types of DME own the equipment
after paying copayments for the item for 13 months. As a member of Tufts Health Plan Medicare Preferred
HMO Prime Rx, however, you usually will not acquire ownership of rented DME items no matter how many
copayments you make for the item while a member of our plan. You can see this on page 61 of the Plans 2022
Evidence of Coverage.

The Plan contract says that the Plan covers all medically necessary equipment covered by Original Medicare. If
a Plan supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can
special order it for you. Durable medical equipment may require prior authorization. You can see this on page
78 of the Plans 2022 Evidence of Coverage.