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 power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a 
physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and 
experience in rehabilitation wheelchair evaluations of the beneficiarys seating and positioning needs. 
The PT, OT, or practitioner may have no financial relationship with the supplier; and 
3. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA) certified Assistive Technology Professional (ATP) 
who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection 
for the beneficiary. 
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to 
independently transfer from the wheelchair to bed; or 
6. The power seating system is needed to manage increased tone or spasticity. 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find these rules in Local Coverage Determination (LCD) Wheelchair Options/Accessories (L33792). 
 
The rules say that if a wheelchair has an electrical connection device described by code E2310 or E2311 and if 
the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as 
non-covered. 
 
You can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (A52504).  
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 say that a Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 6, Section 60.2. 
 
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 also says while you can get your care from an out-of-network provider, the provider must be eligible to 
participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate 
in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for 
the full cost of the services you receive. Check with your provider before receiving services to confirm that 
they are eligible to participate in Medicare. You can find this information on page 39 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 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 a $350 copayment for in-network Medicare-covered surgery services at a 
hospital outpatient facility. You can find this information on page 105 of the Plan's 2022 Evidence of Coverage 
(EOC).  The Plan contract also says that enrollees must pay a $345 copayment per day, for days 1 to 5 and a $0 
copayment for additional days of in-network inpatient hospital care. You can find this information on page 88 
of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $90 copayment for each in-network Medicare-covered 
emergency room visit. You can find this information on page 79 of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $40 copayment for in-network specialist visits. You can 
find this information on page 109 of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $40 copayment for in-network specialist visits. You can 
find this information on page 98 of the Plan's 2023 EOC. 
 
The Plan contract also says that enrollees must pay a $40 copayment for in-network non-routine Medicare-
covered physician services. You can find this information on page 120 of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $5 copayment for in-network lab services. You can find 
this information on page 96 of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $5 copayment for in-network lab services. You can find 
this information on page 83 of the Plan's 2023 EOC. 
 
The Plan contract also says that enrollees must pay 15% coinsurance for in-network simple diagnostic 
radiology. You can find this information on page 97 of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay 15% coinsurance for in-network 15% of the cost of 
diagnostic ultrasounds. You can find this information on pages 82 to 84 of the Plan's 2023 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 pages 37-43 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 Transcatheter Edge-to-Edge Repair (TEER) of the mitral valve is coverable for the treatment 
of symptomatic moderate-to-severe or severe functional mitral regurgitation (MR) when the patient remains 
symptomatic despite stable doses of maximally tolerated guideline-directed medical therapy (GDMT) plus 
cardiac resynchronization therapy, if appropriate, or for the treatment of significant symptomatic degenerative 
MR when furnished according to a Food and Drug Administration (FDA)-approved indication and when all of 
the following conditions are met: 
 
1. The procedure is furnished with a mitral valve TEER system that has received FDA premarket approval 
(PMA). 
 
2. The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, 
multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and 
dedication across medical specialties to offer optimal patient-centered care. 
 
You can find this rule at Centers for Medicare and Medicaid Services, National Coverage Determination 20.33 
entitled Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
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 20% coinsurance for out-of-network outpatient diagnostic tests. You can 
find this information on pages 86 to 87 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that the most you will have to pay out-of-pocket for combined in-network and out-
of-network covered Part A and Part B services in 2022 is $5,000. You can find this information on page 59 of 
the Plan's 2022 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 the following are considered not medically reasonable and necessary: 
1. A genetic test where either analytical validity, clinical validity, or clinical utility has not been 
established. 
2. Genetic testing in patients who do not demonstrate the disease-appropriate phenotype of the gene-
disease association. 
3. Genetic testing of asymptomatic patients. 
4. Genetic testing solely for purposes of proband identification. 
5. Genetic testing with family history as the only indication. 
6. Gene tests for cardiovascular disease are considered germline testing, and therefore only permitted once 
per beneficiarys lifecycle 
You can find this rule in Local Coverage Determination (LCD) Genetic Testing for Cardiovascular Disease 
L39084. 
 
The rules say that pharmacogenetics testing will be considered medically reasonable and necessary if: 1. 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 
2. 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 by CPIC 
guideline level A or B; or is listed in the FDA table of known gene-drug interactions where data support 
therapeutic recommendations or a potential impact on safety or response or the FDA label; 
https://www.fda.gov/drugs/science-and-research-drugs/table-pharmacogenomic-biomarkers-drug-
labeling ; https://www.fda.gov/medical-devices/precision-medicine/table-pharmacogenetic-associations  
You can find this rule in Local Coverage Determination (LCD) 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. 
Thermal destruction of the intraosseous Basivertebral nerve (BVN) will be considered medically reasonable 
and necessary for the treatment of Chronic low back pain (CLBP) in patients who meet ALL the following 
criteria:
1,2,5,9,10,11,12,13
 
1. Chronic lumbar back pain of greater than or equal to 6 months duration that causes functional deficit 
measured on a pain or disability scale*, AND 
2. Documented failure to respond to greater than or equal 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 Magnetic resonance imaging (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. 
You can find this rule in the Local Coverage Determination (LCD): Thermal Destruction of the Intrasseous 
Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 repeat series of injections may be allowed when: 
 
1. The indications continue to be met; and 
2. Significant improvement in pain and functional capacity from the prior series of injections is 
documented in the medical record; and 
3. The last injection (in a prior course) was given at least six (6) months ago. 
 
Repeat injections for shoulder arthritis are limited to a single repeat course. You can find this information in the 
Local Coverage Article: Billing and Coding: Hyaluronans Intra-articular Injections of (A52420). 
 
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 a Medicare plan may restrict enrollees 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 outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 9 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 state that Molecular Diagnostic Services Program (MolDX) will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. 
 
You can find this information in the Local Coverage Determination (LCD) MolDX: Molecular Diagnostic 
Tests (MDT) L35160. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator P means that these codes are bundled/excluded 
codes. There are no relative value units, and no payment amounts for these services. No separate payment is 
made for them under the fee schedule. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.