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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 160.7. 
 
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 intensity modulated radiation therapy (IMRT) is clinically indicated when highly conformal 
dose planning is required. IMRT planning may be clinically indicated when one or more of the following 
conditions are present: 
- An immediately adjacent area has been previously irradiated and abutting portals must be established with 
high precision. 
- Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors 
with conventional treatment. 
- The target volume is concave or convex, and the critical normal tissues are within or around that convexity or 
concavity. 
- The target volume is in close proximity to critical structures that must be protected. 
- The volume of interest must be covered with narrow margins to adequately protect immediately adjacent 
structures. 
 
Clinical scenarios that would not typically support the use of IMRT include: 
- where IMRT does not offer an advantage over conventional or three-dimensional conformal radiation therapy 
techniques that deliver good clinical outcomes and low toxicity 
- clinical urgency, such as spinal cord compression, superior vena cave syndrome or airway obstruction 
- palliative treatment of metastatic disease where the prescribed dose does not approach normal tissue 
tolerances 
- inability to accommodate for organ motion, such as for a mobile lung tumor 
- inability of the patient to cooperate and tolerate immobilization to permit accurate and reproducible dose 
delivery. 
 
You can find this information in the Local Coverage Determination (LCD): Intensity Modulated Radiation 
Therapy (IMRT) (L36773). 
 
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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules state that for antigens provided to patients on or after November 17, 1996, Medicare does not cover 
such antigens if they are to be administered sublingually, i.e., by placing drops under the patient's tongue. This 
kind of allergy therapy has not been proven to be safe and effective. Antigens are covered only if they are 
administered by injection. You can find this information in the National Coverage Determination (NCD) 
Antigens Prepared for Sublingual Administration 110.9  
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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.
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 wearable defibrillator (K0606) is covered for beneficiaries if they meet one of the criteria 
(1-4), described below: 
1. A documented episode of ventricular fibrillation or a sustained, lasting 30 seconds or longer, ventricular 
tachyarrhythmia. These dysrhythmias may be either spontaneous or induced during an electrophysiologic (EP) 
study, but may not be due to a transient or reversible cause and not occur during the first 48 hours of an acute 
myocardial infarction; or 
2. Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia such as long 
QT syndrome or hypertrophic cardiomyopathy; or 
3. Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular 
ejection fraction less than or equal to 0.35; or 
4. A previously implanted defibrillator now requires explantation. 
You can find this information in the Local Coverage Determination (LCD): Automatic External Defibrillators 
(L33690). 
 
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 Psychological and Neuropsychological testing is not considered reasonable and necessary 
when: 
 the patient is not neurologically and cognitively able to participate in a meaningful way in the testing 
process 
 administered for educational or vocational purposes that do not establish medical management 
 performed when abnormalities of brain or emotional function are not suspected 
 used for self-administered or self-scored inventories or screening tests of cognitive function (paper-and-
pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination 
 Repeated when not required for medical decision-making. Examples of medical decision making 
include: whether to start or continue a particular rehabilitative or pharmacologic therapy); 
 Administered when the patient has a substance abuse background, and any of the following apply: the 
patient has ongoing substance abuse such that test results would be inaccurate, or the patient is currently 
intoxicated. 
Testing conducted when no mental illness/disability is suspected would be considered screening and would not 
be covered. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an 
acceptable indication for testing. You can find the rules in Local Coverage Determination (LCD) Psychological 
and Neuropsychological Tests L34520. 
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 20 one-way trips per calendar year. You can find this information on page 94 of the Plans 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 state that the reasonable useful lifetime of a durable medical equipment (DME) item may in no case 
be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but 
not actual replacement) for medically necessary equipment. You can find this rule in Medicare Benefit Policy 
Manual Chapter 15, Section 110.2(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.
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. 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. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A56853. 
 
The rules state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
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 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
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 transluminal angioplasty (PTA) is covered for the following indications: 
1. Treatment of atherosclerotic obstructive lesions 
2. Concurrent with carotid stent placement in approved Category B Investigational Device Exemption 
(IDE) clinical trials 
3. Concurrent with carotid stent placement in approved post-approval studies 
4. Concurrent with carotid stent placement in patients at high risk for carotid endarterectomy (CEA) 
5. Concurrent with intracranial stent placement in approved Category B IDE clinical trials 
 
All other indications for PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral 
arteries remain non-covered. All other indications for PTA without stenting for which Medicare has not 
specifically indicated coverage remain noncovered. You can find these rules in National Coverage 
Determination (NCD) Percutaneous Transluminal Angioplasty (20.7). 
 
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 viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when ALL of the following conditions are 
met: 
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of 
daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee 
stiffness. 
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint 
space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due 
to a diagnosis other than osteoarthritis of the knee). 
4. The patient has failed at least three months of conservative therapy.  
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients 
symptoms and intra-articular corticosteroids are not contraindicated. 
 
A repeat series of hyaluronan knee injection(s) for patients who have responded to a prior series is considered 
to be reasonable and necessary under the following circumstances: 
 Symptoms have recurred and, 
 At least six months have elapsed since the prior series of injections and, 
 There was significant improvement in pain and functional capacity achieved with the prior series of 
injections using a standardized assessment tool or, 
 There is significant reduction in the doses of NSAID medications taken or reduction in the number of 
intra-articular steroid injections to the knees during the six-month period following the injection(s). 
 
You can find this rule in the Local Coverage Determination for Hyaluronan Acid Therapies for Osteoarthritis 
of the Knee, L35427.  
 
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 payment may be made under the prosthetic device benefit for implanted peripheral nerve 
stimulators. Use of this stimulator involves implantation of electrodes around a selected peripheral nerve. The 
stimulating electrode is connected by an insulated lead to a receiver unit which is implanted under the skin at a 
depth not greater than 1/2 inch. 
 
Stimulation is induced by a generator connected to an antenna unit which is attached to the skin surface over 
the receiver unit. Implantation of electrodes requires surgery and usually necessitates an operating room. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations Manual, Section 160.7. 
 
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 state that a custom fabricated mandibular advancement oral appliance (E0486) used to treat 
obstructive sleep apnea (OSA) is covered if criteria A - D are met. 
 
    A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to  
    assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-related 
    Policy Article for applicable diagnoses. 
    B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3): 
        1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15  
        events per hour with a minimum of 30 events; or, 
        2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a  
        minimum of 10 events and documentation of: 
            a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
            b. Hypertension, ischemic heart disease, or history of stroke; or, 
        3. If the AHI is greater than 30 or the RDI is greater than 30 and meets either of the following (a or b): 
            a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
            b. The treating practitioner determines that the use of a PAP device is contraindicated. 
    C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The  
    practitioner who provides the order for the oral appliance could be different from the one who performed the 
    clinical evaluation in criterion A.) 
    D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Oral Appliances for Obstructive 
Sleep Apnea (L33611). 
 
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.