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 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 PTA and stenting of vessels is covered only when all of the following conditions are met: 
 The patient has undergone prior thorough medical evaluation and management of symptoms. See below 
under specific categories for guidelines on medical evaluation and management recommendations. 
 Surgical intervention would otherwise be considered as an alternative treatment for the patient. 
 A stent may be placed as a planned adjunct to PTA rather than in response to a suboptimal or failed 
PTA (so-called primary stent deployment). Primary stenting is justified for situations where PTA alone 
is not expected to provide a durable result, such as arterial or venous occlusions that carry a high risk 
for distal embolization or rapid recurrence OR occlusive lesions known to be unfavorable for PTA 
alone such as significantly calcified lesions, eccentric lesions, lesions related to external compression 
(e.g., May-Thurner syndrome and malignant compression of the superior vena cava), or ostial renal 
artery stenosis. 
You can find the rules in Local Coverage Determination (LCD) Non-Coronary Vascular Stents L35998. 
 
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 covers leadless pacemakers when procedures are performed in Food and Drug 
Administration (FDA) approved studies. Medicare also covers, in prospective longitudinal studies, leadless 
pacemakers that are used in accordance with the FDA approved label for devices that have either: 
 
- an associated ongoing FDA approved post-approval study; or 
- completed an FDA post-approval study. 
 
You can find this information in National Coverage Determination (NCD): Leadless Pacemakers (20.8.4). 
 
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 an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar 
paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients 
who have had at least two (2) medically reasonable and necessary diagnostic medial branch block (MBBs), 
with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the 
duration of relief being consistent with the agent used). You can find this information in Medicare's 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.
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 30-day period of care is the unit of payment for the home health prospective payment 
system (HH PPS). The period of care payment is specific to one individual homebound beneficiary. It pays all 
Medicare covered home care that is reasonable and necessary for the patient's care, including routine and 
nonroutine supplies used by that beneficiary during the period of care. For periods of care beginning on or after 
January 1, 2020, the duration of a period is 30 days. Periods of care may be shorter than 30 days. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 10, Section 10.1.4 and 10.1.5. 
 
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 March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
   a. Patient has: 
 
    i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
   ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
  iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
   b. The diagnostic laboratory test using NGS must have: 
 
    i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
   ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
  iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this information in the National Coverage Determination (NCD) for Next Generation Sequencing 
(NGS) (90.2). 
 
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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say a Group 2 Multiple Power Option PWC (K0841, K0842, K0843) is covered if all of the coverage 
criteria (a)-(e) for a PWC are met and if:  
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met.  
1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see 
Wheelchair Options and Accessories policy) and the system is being used on the wheelchair. 
2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a PT or OT, or practitioner who has specific training and 
experience in rehabilitation wheelchair evaluations and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, 
or practitioner may have no financial relationship with the supplier. 
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology 
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in 
the wheelchair selection for the beneficiary. 
If a Group 2 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be 
denied as not reasonable and necessary. You can find this rule 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 state that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. Both the physician ordering the test and the entity that submits the claim must 
maintain documentation of medical necessity in the beneficiarys medical record. You can find this information 
in the 42 CFR Section 410.32 
 
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 in most cases, you will need approval from your primary care physician (PCP) before using other 
providers. This approval is called a referral. You can get the following services without first getting approval 
from your PCP: Emergency services from network providers or out-of-network providers, Urgently needed 
care from network providers, Urgently needed care from out-of-network providers when you cannot get to 
network providers, Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are 
outside the plans service area, Flu shots and COVID-19 vaccinations as well as hepatitis B vaccinations and 
pneumonia vaccinations as long as you get them from a network provider, Routine womens health care, 
Family planning services, and Additionally, if you are eligible to get services from Indian health providers, you 
may use these providers without a referral. You can find this information on page 32 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. 
 
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 up to 60 one-way trips are covered each year (limited to ground transportation only). You can find this 
information on page 4-59 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 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 up to 24 one-way trips, combined in and out-of-network, are covered each year (limited to ground 
transportation only). Each one-way trip must not exceed 50 miles of driving distance. You can find this 
information 4-77 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 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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 7 to 8 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 state that a Medicare Advantage (MA) organization that offers an MA coordinated care plan may 
specify the networks of providers from whom enrollees may obtain services if the MA organization ensure that 
all covered services, including supplemental services contracted for by the Medicare enrollee, are available and 
accessible under the plan. To accomplish this, the MA organization must ensure that services are provided in a 
culturally competent manner to all enrollees, including those with limited English proficiency or reading skills, 
and diverse cultural and ethnic backgrounds. You can find this rule in 42 Code of Federal Regulations (CFR) 
Section 422.112(a)(8). 
 
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. Covered 
services include physical therapy, occupational therapy, and speech language therapy. Outpatient rehabilitation 
services are provided in various outpatient settings, such as hospital outpatient departments, independent 
therapist offices, and comprehensive outpatient rehabilitation facilities (CORF's). You can find this information 
on page 95 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. 
 
The rules say that because the available language in the current HIPAA compliant code sets used to describe 
the pathology and laboratory categories and the tests included in those categories are not specific to the actual 
test results provided, all MDT services must include an identifier as additional claim documentation. Test 
providers must receive an identifier specific to the applicable test and submit the test assigned identifier with 
the claim for reimbursement. The assigned identifier will provide a crosswalk between the tests associated 
detail information on file and the submitted claim detail line(s) required to adjudicate each tests claim. The 
unique identifier limits the need to submit the required additional information about the test on each claim. You 
can find this information in Medicare's Local Coverage Determination (LCD): MolDX: Molecular Diagnostic 
Tests (MDT) (L35025). 
 
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 TAVR is covered for uses that are not expressly listed as an FDA-approved indication when 
performed within a clinical study. You can find these rules in the Medicare National Coverage Determination 
(NCD) for Transcatheter Aortic Valve Replacement (TAVR), Section 20.32. 
 
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 because the available language in the current HIPAA compliant code sets used to describe the 
pathology and laboratory categories and the tests included in those categories are not specific to the actual test 
results provided, all MDT services must include an identifier as additional claim documentation. Test providers 
must receive an identifier specific to the applicable test and submit the test assigned identifier with the claim 
for reimbursement. The assigned identifier will provide a crosswalk between the tests associated detail 
information on file and the submitted claim detail line(s) required to adjudicate each tests claim. The unique 
identifier limits the need to submit the required additional information about the test on each claim. You can 
find this information in Medicare's 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 codes L5940, L5950, and L5960 for ultra-light materials may only be used when materials 
such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the 
fabrication of a socket for an endoskeletal prosthesis. They are not used for ultralight materials used in other 
components of a prosthesis  e.g., knee/shin system, pylon, ankle, foot. You can find this rule in the Local 
Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 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 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 procedure codes included in a dental benefits chart. Bone replacement graft (D7953) and guided tissue 
regeneration (D4266) are not among the services covered by the Plan's dental benefits. You can find this 
information in Schedule A, Description of Benefits and Copayments on pages 13-34 of the Plans 2022 Dental 
Health Care Program Combined Benefit Booklet.