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 epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following requirements are met: 
 
- History, physical examination, and concordant radiological image-based diagnostic testing that supports 
one of the following
: 
 
 
     -Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to  
      disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing  
      foraminal or central spinal stenosis
 
OR 
     -Post-laminectomy syndrome, OR 
     -Acute herpes zoster associated pain. 
       AND 
- Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality 
of life or function. An objective pain scale or functional assessment must be performed at baseline 
(prior to interventions). The same scale must be used at each follow-up for assessment of response. 
        AND 
- Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or 
acute herpes zoster refractory to conservative management where a four (4) week wait is not required. 
You can find this information in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L36920). 
 
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 also say that an implanted loop recorder (ILR) is used when syncope is thought to be cardiac-related, 
but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom MLR. Such 
recorders may be covered to: Detect, characterize, and document symptomatic transient arrhythmias; Initiate, 
revise, or discontinue arrhythmic drug therapy; or, Carry-out early post-hospital monitoring of patients 
discharged after myocardial infarction (MI). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-02, National Coverage Determinations Manual, 
Section 20.15. 
 
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 Medicare guidelines say EACH biomarker test (%fPSA, PHI, 4Kscore, or EPI) is covered ONCE in men 
45 years old ( 50 years old for EPI) prior to initial biopsy, with confirmed* moderately elevated PSA (>3 and
75 years old) with BOTH the following: 1. No other relative indication for prostate biopsy including ANY of
the following: a) DRE suspicious for cancer b) Positive multiparametric MRI (if done) c) Other major risk
factor for prostate cancer including: i. Ethnicity at higher risk for prostate cancer^ ii. First-degree relative with
prostate cancer. You can find this rule in the Local Coverage Determination (LCD): Biomarker Testing (Prior
to Initial Biopsy) for Prostate Cancer Diagnosis (L37733).
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 effective for services performed on or after July 1, 1999, VNS is reasonable and necessary 
for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom 
surgery has failed. 
 
Effective for services performed on or after February 15, 2019, the Centers for Medicare & Medicaid Services 
(CMS) will cover FDA-approved VNS devices for treatment resistant depression (TRD) through Coverage 
with Evidence Development (CED) when offered in a CMS-approved, double-blind, randomized, placebo-
controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a 
prospective longitudinal study when the CMS-approved, double-blind, randomized placebo-controlled trial has 
completed enrollment, and there are positive interim findings. You can find these rules in National Coverage 
Determination (NCD) Vagus Nerve Stimulation (VNS) 160.18. 
 
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 state that a supplemental benefit is an item or service not covered by original Medicare, that is 
primarily health related and for which the MA plan must incur a non-zero direct medical cost. Supplemental 
benefits need not be provided through Medicare providers nor at Medicare certified facilities. You can find this 
rule in the Medicare Managed Care Manual, Chapter 4, Section 30.1. 
 
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. The Plan 
contract also says that the Plan covers a Pick Your Perks reimbursement program with over-the-counter (OTC) 
items. These items are clearly noted on the Plans allowed items list. Ineligible items include, but are not 
limited to, the following: Alternative medicines such as botanicals herbals, probiotics and nutraceuticals. You can 
find this information on page 97 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 20 one-way routine transportation trips per calendar year. You can find this information on page 
101 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 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. 
 
The rules say that payment is not made under the physician fee schedule for Technical Component (TC) 
services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., 
hospital inpatient and outpatient settings. Payment is made under the physician fee schedule for TC services 
furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an 
ambulatory surgery center (ASC). Payment may be made under the physician fee schedule for the TC of 
physician pathology services furnished by an independent laboratory, or a hospital if it is acting as an 
independent laboratory, to non-hospital patients. The physician fee schedule identifies physician laboratory or 
physician pathology services that have a TC service. 
 
For TC services furnished by independent laboratories to hospital inpatients and outpatients on or after July 1, 
2012, an independent laboratory may not bill the A/B Medicare Administrative Contractor (MAC) (B) (and the 
A/B MAC (B) may not pay) for the TC component of a physician pathology service furnished to a hospital 
inpatient or outpatient. 
 You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 60. 
 
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. The Plan contract also says that in general, criteria for crowns will be met only for permanent teeth needing multi-surface restorations where other restorative materials have a poor prognosis. Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma and should involve three or more surfaces and at least one cusp. You can find this information in the Plan's dental vendor's 2022 Clinical Criteria for Removable Prosthodontics.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that a Medicare plan may not pay for services given by a physician or other practitioner who has opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 6, Section 60.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that you may see any licensed dental provider who accepts Medicare patients in the U.S. and has not opted out of Original Medicare. You can find this information on page 68 of the Plan's 2021 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 a PCD coded as E0652, is covered for the treatment of lymphedema extending onto the 
chest, trunk and/or abdomen when all of the following are met: 
 The beneficiary has lymphedema of an extremity as defined above 
 The coverage criteria for an E0650 or E0651 are met 
 The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed 
to improve with a four-week trial. (See below for trial guidelines.) 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. You can find this rule at Local Coverage Determination (LCD) L33829: Pneumatic 
Compression Devices (eff. 1/1/20). 
 
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 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 23 to 24 of the Plan's 2022 Schedule of Cost-Sharing.
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 in the locality, the Medicare allowable non-facility non-participating price for code 96365 (intravenous infusion - initial) is $70.41 for dates of service in 2021 and $66.20 for dates of service in 2022. You can find these rules in the 2021 and 2022 Medicare Physician Fee Schedule. The rules say that when services or supplies are rendered by a non-contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the enrollee. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, 170.2.
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.
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 doctor's 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 twenty-four (24) one-way trips per year. You can find this information on page 111 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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rule say that Place of Service (POS) code 31 should be used with services for patients in a Part A covered 
stay and POS code 32 should be used with services for beneficiaries in a noncovered stay. A/B MACs (B) 
should adjust their prepayment procedure edits as appropriate. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Pub 100-04, Medicare Claims Processing Manual, 
Chapter 6, Section 110.1 - Correct Place of Service (POS) Code for SNF Claims. 
 
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.