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 stress testing with cardiac imaging will be considered medically reasonable and necessary 
for patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained 
angina equivalent symptoms, and any of the following: 
- Physical inability to perform a maximum exercise workload 
- New or previously unrecognized uninterpretable electrocardiogram (ECG) 
~ ECG is uninterpretable for ischemia due to any one of the following: 
- Complete left bundle branch block (right bundle branch does not render ECG 
uninterpretable for ischemia), 
- Ventricular paced rhythm, 
- Pre-excitation pattern such as Wolff-Parkinson-White, 
- A greater than 1 mm ST segment depression (NOT nonspecific ST/T wave changes), 
- Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH 
with strain (NOT without repolarization abnormalities or by voltage criteria), or 
- Patient on digoxin therapy. 
- A history of coronary artery disease (CAD) based on a prior anatomic evaluation of the coronary 
arteries or a history of coronary artery bypass graft (CABG) or percutaneous coronary intervention 
(PCI); 
- Syncope and collapse (an abrupt, transient, complete loss of consciousness) for patients with an 
intermediate or high congestive heart disease (CHD) risk and where cardiac etiology is suspected based 
on an initial evaluation, including history, physical examination, or ECG and patient is unable to 
exercise; 
- Evidence or high suspicion of ventricular arrhythmias; 
- Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test 
and there is suspicion of a false negative result; 
- Patients with recent equivocal or borderline testing where ischemia remains a concern; 
- Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the 
documentation supports that an adequate workload may not be attainable to enable a fully diagnostic 
exercise study; - History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not 
appear to be due to macrovascular CAD); 
- Evaluation of chest pain syndrome after revascularization or in patients with intermediate to high pre-
test probability for CAD regardless of ECG interpretability or ability to exercise; 
- High pre-test probability for CAD regardless of ECG interpretability or the ability to exercise, and a 
decision to perform cardiac catheterization or other angiography has not already been made; 
- Patients with hypertrophic cardiomyopathy (HCM); 
 
You can find these rules in Local Coverage Determination (LCD) Cardiology Non-emergent Outpatient Stress 
Testing (L35083). 
 
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 a $40 copayment for outpatient rehabilitation services. The enrollee must 
pay a $40 copayment for Medicare covered physical, occupational and speech therapy visits. Please note, if the 
provider bills a PT visit that is less than the $40 then that amount is your copay. You can find this information 
on page(s) 80 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 state that duplex scanning of the lower extremity arteries performed to establish the level and/or 
degree of arterial occlusive disease, will be considered medically necessary if a) significant signs and/or 
symptoms indicate a high likelihood of limb ischemia, and b) the patient is a candidate for invasive therapeutic 
procedures under any of the following circumstances: 
- The patient has symptoms of peripheral vascular ischemia and is found on physical examination to have 
absence or marked diminution of pulses (suspected to be secondary to obstruction of lower extremity 
arteries) of one or both lower extremities.  
- The patient has developed sudden pallor, numbness, and coolness of an extremity and vascular 
obstruction (embolism or thrombosis) is suspected.  
- Claudication of less than one block or of such severity that it interferes significantly with the patient's 
occupation or lifestyle. 
- The patient has an aneurysm or arteriovenous malformation of a lower extremity artery. 
- The patient has sustained lower extremity trauma with possible vascular injury or the patient has 
sustained iatrogenic vascular injury. 
- Rest pain of ischemic origin (typically including the forefoot), associated with absent pulses, which 
becomes increasingly severe with elevation and diminishes with placement of the leg in a dependent 
position. 
- Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of 
the extremity occurring in the absence of pulses. 
You can find these rules in Local Coverage Determination (LCD) Duplex Scan of Lower Extremity Arteries 
(L33667). 
 
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 a $25 copayment for Medicare-covered non-radiological diagnostic 
services. You can find this information on pages 4-43 to 4-47 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $25 copayment for Medicare-covered radiological diagnostic 
services, not including X-rays. You can find this information on pages 4-43 to 4-47 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 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 
D3331. You can find this information on page 120 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 apheresis is covered for the following indications: 
 Plasma exchange for acquired myasthenia gravis; 
 Leukapheresis in the treatment of leukemia; 
 Plasmapheresis in the treatment of primary macroglobulinemia (Waldenstrom); 
 Treatment of hyperglobulinemias, including (but not limited to) multiple myelomas, cryoglobulinemia 
and hyperviscosity syndromes; 
 Plasmapheresis or plasma exchange as a last resort treatment of thromobotic thrombocytopenic purpura 
(TTP); 
 Plasmapheresis or plasma exchange in the last resort treatment of life threatening rheumatoid vasculitis; 
 Plasma perfusion of charcoal filters for treatment of pruritis of cholestatic liver disease; 
 Plasma exchange in the treatment of Goodpasture's Syndrome; 
 Plasma exchange in the treatment of glomerulonephritis associated with antiglomerular basement 
membrane antibodies and advancing renal failure or pulmonary hemorrhage; 
 Treatment of chronic relapsing polyneuropathy for patients with severe or life-threatening symptoms 
who have failed to respond to conventional therapy; 
 Treatment of life-threatening scleroderma and polymyositis when the patient is unresponsive to 
conventional therapy; 
 Treatment of Guillain-Barre Syndrome; and 
 Treatment of last resort for life threatening systemic lupus erythematosus (SLE) when conventional 
therapy has failed to prevent clinical deterioration. 
 
You can find these rules in National Coverage Determination (NCD) Apheresis (Therapeutic Pheresis) 110.14. 
 
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 posterior tibial nerve stimulation is covered for treatment of urinary urgency, urinary 
frequency, and urge incontinence. The patients medical record must contain adequate documentation 
identifying the CPT and ICD-10-CM coding, and the need for and level of these visits. You can find this rule 
in the Local Coverage Article (LCA) - Billing and Coding: Posterior Tibial Nerve Stimulation Coverage 
(A55104). 
 
The rules say that coverage for initial therapy must document failed standard anticholinergic drug therapy or 
that the patient demonstrates intolerance to the anticholinergic drug therapy despite best attempts at 
management of the most common side effects of such therapy, such as dry mouth and constipation. You can 
find this rule in the Local Coverage Article (LCA) - Billing and Coding: Posterior Tibial Nerve Stimulation 
Coverage (A55104). 
 
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 
D5211. You can find this information on pages 80-82 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 this LCD addresses use of water vapor thermal therapy for the treatment of lower urinary 
tract symptoms attributable to benign prostatic hyperplasia (LUTS/BPH).  
 
ONE treatment for LUTS/BPH treatment is covered ONCE in patients with BOTH the following:  
 
Indications including ALL of the following: 
 
Age =50 
 
Symptomatic despite maximal medical management including ALL of the following: 
 
International Prostate Symptom Score (IPSS) =13 
 
Maximum urinary flow rate (Qmax) of =15 mL/s (voided volume greater than 125 cc) 
 
Failure, contraindication or intolerance to at least three months of conventional medical therapy for BPH (e.g., 
alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
Prostate volume of 30-80 cc, 
 
Poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, 
pulmonary disease, etc.), or at high risk of bleeding 
 
No contraindications including ALL of the following: 
 
Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines) or a prostate 
specific antigen (PSA) >10 ng/mL 
 
Active urinary tract infection  
History of bacterial prostatitis in the past three months 
 
Prior prostate surgery 
 
Neurogenic bladder 
 
Active urethral stricture (i.e., the source of the current LUTS) 
 
You can find this information in the Local Coverage Determination (LCD) Water Vapor Thermal Therapy for 
LUTS/BPH L37808. 
 
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 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 single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
stress fracture. 
spondylosis. 
infection (e.g., discitis). 
tumor (e.g., osteoid osteoma). 
analyze blood flow to an organ, as in the case of myocardial viability. 
differentiate ischemic heart disease from dilated cardiomyopathy. 
 
Indications and Limitations of Coverage 
Frequency limitations: Medicare Administrative Contractor discretion. 
 
In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT 
that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET 
performed to evaluate myocardial viability. 
 
You can find this information in the National Coverage Determination (NCD) Single Photon Emission 
Computed Tomography (SPECT) 220.12. 
 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 one 
D0150 every three calendar years. This benefit does not include D0365. You can find this information on pages 
81-82 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 state that Testing must be based on clinicians documented medical necessity and reviewed by the 
clinician in the management of prescribing/renewing a controlled substance for every risk group outlined 
  
  below:  
 
Risk Group:  
 
Low Risk: 
Baseline: Prior to initiation of COT 
Risk Level: Random testing 1-2 times every 12 months for prescribed medications, non-prescribed medications 
that may pose a safety risk if taken with prescribed medications, and illicit substances based on patient history, 
clinical presentation, and/or community usage. 
 
Risk Group 
 
Moderate Risk: 
Baseline: Prior to initiation of COT 
Risk Level: Random testing 1-2 times every 6 months for prescription medications, non-prescribed medication 
that may pose a safety risk if taken with prescribed medications, and illicit substances, based on patient history, 
clinical presentation, and/or community usage. 
 
You can find this information in the Local Coverage Determination (LCD) Controlled Substance Monitoring 
and Drugs of Abuse Testing L36393. 
 
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 state that a group 3 power wheelchair with multiple power options is covered when the enrollee 
meets coverage criteria for a group 3 power wheelchair (the beneficiary's mobility limitation is due to a 
neurological condition, myopathy, or congenital skeletal deformity), and either uses a ventilator mounted to the 
wheelchair or meets coverage criteria for a power tilt and power recline seating system.  
 
The rules also state that if a power wheelchair base is not covered, then related accessories will be denied. This 
information is found in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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 
D7140. You can find this information on pages 59-61 of the Plans 2023 Evidence of Coverage (EOC).