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 Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 60-61 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 left prefrontal rTMS of the brain is considered medically necessary for use in an adult who 
meets all four of the following criteria: 
 
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) single or recurrent episode; and 
2. One or more of the following: 
 Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically 
significant response to two trials of psychopharmacologic agents in the current depressive episode from 
at least two different agent classes. 
 At least one of the treatment trials must have been administered at an adequate course of mono- or poly-
drug therapy; or 
 Inability to tolerate psychopharmacologic agents as evidenced by four trials of psychopharmacologic 
agents from at least two different agent classes, with distinct side effects; or 
 History of response to rTMS in a previous depressive episode; or 
If patient is currently receiving electro-convulsive therapy, rTMS may be considered reasonable and 
necessary as a less invasive treatment option. 
Resistance to treatment is defined by a failure to achieve a 50% reduction in depressive symptoms, in 
accordance with objective measures such as PHQ-9 and/or HAM-D, from a pharmacologic trial where the 
medication is administered at the recommended adult dose, per the FDA label, for a period of not less than 6 
weeks. 
 
Psychopharmacologic agent side effects will be considered intolerable, when those side effect are of a nature 
where they are not expected to diminish or resolve with continued administration of the drug 
 
AND 
 
3. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate 
frequency and duration without significant improvement in depressive symptoms as documented by 
standardized rating scales that reliably measure depressive symptoms. 
 
AND 
 
4. The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the 
patient and reviewed the record. The psychiatrist will have experience in administering TMS therapy. The treatment shall be given under direct supervision of this psychiatrist (physician present in the area and 
immediately available but does not necessarily personally provide the treatment). 
You can find this information in Local Coverage Determination (LCD): Transcranial Magnetic Stimulation 
(TMS) (L36469). 
 
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 coverage of Vitamin B12 injections is limited to the following: 
 
1. The patient has a history of low serum B12 or conditions causing or caused by low serum B12; or 
2. When administered as an adjunct to pemetrexed or pralatrexate treatment. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L33967 
entitled "Vitamin B12 Injections." 
 
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 stenting of vessels is covered only when all of the following conditions are met: 
 Angioplasty alone would not suffice. 
 The patient has undergone prior thorough medical evaluation and management of symptoms for which 
PTA and stent are therapeutic. 
 Surgical intervention would otherwise be considered as an alternative treatment for the patient. 
 Condition(s) exists for which there is evidence of equal outcomes with renal artery intervention and 
medical therapy when compared with outcome of medical or surgical management. 
 
The rules also say that stent placement in the lower extremity arteries (aorto-iliac, iliac, superficial femoral and 
infrapopliteal arteries) may be necessary for: lifestyle-limiting claudication, focal hemodynamically 
significant lesion, ischemic rest pain, non-healing tissue ulceration and focal gangrene. Stent placement in 
infrapopliteal vessels is not expected to be often indicated and in those cases the rationale for stent placement 
must be explained in the record. You can find this information in Local Coverage Determination (LCD): Non-
Coronary Vascular Stents (L35084). 
 
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 thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
a. Initial thermal RFA: 
i. After the patient has had at least two (2) medically reasonable and necessary diagnostic 
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) AND 
ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically 
reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement 
in the ability to perform previously painful movements and ADLs as compared to 
baseline measurement using the same scale 
You can find this rule at Local Coverage Determination (LCD) L38803: Facet Joint Interventions for Pain 
Management (eff. 2/3/22). 
 
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 positron emission tomography (PET) scans performed at rest or with pharmacological stress 
used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with 
known or suspected coronary artery disease using the FDA-approved radiopharmaceutical Rubidium 82 (Rb 
82), or ammonia N-13 are covered, provided the requirements below are met: 
 
The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a 
single-photon emission computed tomography (SPECT) scan; or  
The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be 
inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what 
medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an 
inconclusive test is a test whose results are equivocal, technically uninterpretable, or discordant with a patient's 
other clinical data and must be documented in the beneficiary's file.)  
 
You can find this information in Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 220.6.1. 
 
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. 
 
Medicare guidance says screening tests without a valid medical diagnosis related to the health of the patient are 
not a benefit. You can find this Medicare guidance in the National Coverage Determination (NCD) for 
Glycated Hemoglobin/Glycated Protein (190.21), National Coverage Determination (NCD) for Serum Iron 
Studies (190.18), National Coverage Determination (NCD) for Gamma Glutamyl Transferase (190.32) and 
Local Coverage Determination (LCD): Assays for Vitamins and Metabolic Function (L33418). 
 
Please refer to the Related Links section of the CMS NCCI PTP coding edits page to download the PTP coding 
spreadsheet that corresponds to the calendar year of the date-of-service 
(https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html). 
 
The rules say that screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
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 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 page 9 of the 2023 Evidence 
of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 the 
intraoral - periapical first radiographic image (D0220) but is limited to 1 procedure code per calendar year. 
This benefit does not cover the cone beam CT capture and interpretation (D0364), occlusal adjustment - limited 
(D9951), incomplete endodontic therapy; (D3332), and limited oral evaluation - problem focused (D0140). 
You can find this information on pages 91-92 of the Plan's 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 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 there are specific diagnosis codes which support the medical necessity of CPT code 83540. 
Any diagnosis codes that are not listed do not support the medical necessity of CPT code 83540. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
National Coverage Determinations (NCD) Manual: Serum Iron Studies, NCD 190.18 and the NCD Coding 
Policy Manual and Change Report (ICD-10-CM) 190.18. 
 
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 beneficiary can be covered for an unlimited number of nonoverlapping episodes. The 
duration of a single full-length episode is 60 days. Episodes may be shorter than 60 days. 
 
For example, an episode may end before the 60th day in the case of a transfer to another HHA, or a discharge 
and readmission to the same HHA, and payment is pro-rated for these shortened episodes, in which more home 
care is delivered in the same 60-day period. Claims for episodes may be submitted prior to the 60th day if the 
beneficiary has been discharged and treatment goals have been met, though payment will not be pro-rated 
unless more home health care is subsequently billed in the same 60-day period. You can find this rule in the 
Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Medicare Claims Processing 
Manual, Chapter 10, Section 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 state that a battery charger (E2366, E2367) is included in the allowance for a power wheelchair base. 
You can find this information in the Local Coverage Article Wheelchair Options/Accessories - Policy Article 
A52504. 
 
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 a microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), 
dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal 
(L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose 
functional level is 3 or above. 
 
A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, 
L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for 
beneficiaries whose functional level is 3 or above.  
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, 
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY 
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below: 
1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
2. K3 functional level only 
3. Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or 
quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee 
alone 
4. Is able to make use of a product that requires daily charging 
5. Is able to understand and respond to error alerts and alarms indicating problems with the function of the 
unit 
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. You can find this rule in Local Coverage Determination (LCD) Lower Limb Prostheses L33787.  
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. 
 
an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and 
documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. These 
patients have been evaluated for specific alternate neurodegenerative diseases or other causative factors, but the 
cause of the clinical symptoms remains uncertain. You can find this information in Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
(NCD) Manual Section 220.6.13. 
 
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.