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 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. 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. 
 
The rules say that Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of 
the following qualified skilled services:  
 
  
  1. Skilled nursing care;  
2. Physical therapy;  
3. Occupational therapy; or  
4. Speech pathology services.  
 
HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, 
home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 
and 409.45. 
 
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 
 
Indications and Limitations of Coverage 
 
    a. CMS continues to nationally cover FDG PET imaging for the initial anti-tumor treatment strategy for male 
and female breast cancer only when used in staging distant metastasis. 
    b. CMS continues to nationally cover FDG PET to determine initial anti-tumor treatment strategy for 
melanoma other than for the evaluation of regional lymph nodes. 
    c. CMS continues to nationally cover FDG PET imaging for the detection of pre-treatment metastasis (i.e., 
staging) in newly diagnosed cervical cancers following conventional imaging. 
 
C.1      Initial Anti-Tumor Treatment Strategy Nationally Non-Covered Indications 
 
    a. CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who 
have adenocarcinoma of the prostate. 
    b. CMS continues to nationally non-cover FDG PET imaging for diagnosis of breast cancer and initial 
staging of axillary nodes. 
    c. CMS continues to nationally non-cover FDG PET imaging for initial anti-tumor treatment strategy for the 
evaluation of regional lymph nodes in melanoma. 
    d. CMS continues to nationally non-cover FDG PET imaging for the diagnosis of cervical cancer related to 
initial anti-tumor treatment strategy. 
 
3.      Subsequent Anti-Tumor Treatment Strategy 
 
B.2.      Subsequent Anti-Tumor Treatment Strategy Nationally Covered Indications 
 
Three FDG PET scans are nationally covered when used to guide subsequent management of anti-tumor 
treatment strategy after completion of initial anti-cancer therapy. Coverage of more than three FDG PET scans 
to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy 
shall be determined by the local Medicare Administrative Contractors. 
 
4.      Synopsis of Coverage of FDG PET for Oncologic Conditions 
  
You can find this information in Medicare's National Coverage Determination (NCD): Positron Emission 
Tomography (FDG) for Oncologic Conditions (220.6.17). 
 
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. 
 
To be considered reasonable and necessary, the services must meet Medicare guidelines. The guidelines for 
coverage of outpatient therapies have basic requirements in common. 
 
In the case of rehabilitative therapy, the patients condition has the potential to improve or is improving in 
response to therapy, maximum improvement is yet to be attained; and there is an expectation that the 
anticipated improvement is attainable in a reasonable and generally predictable period of time. Refer to CMS 
Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C). 
 
For example, therapy may not be covered for a fully functional patient who developed temporary weakness 
from a brief period of bed rest following abdominal surgery. It is reasonably expected that as discomfort 
reduces and the patient gradually resumes daily activities, function will return without skilled therapy 
intervention. 
 
If the goal of the plan of care is to improve functioning, the documentation must establish that the patient needs 
the unique skills of a therapist to improve functioning. If the goal of the plan of care is to maintain, prevent or 
slow further deterioration of functional status function or prevent deterioration, the documentation must 
establish that the patient needs the unique skills of a therapist to maintain, prevent or slow further deterioration 
of functional status. All services provided are to be specific and effective treatments for the patients condition 
according to accepted standards of medical practice; and the amount, frequency, and duration of the services 
must be reasonable. 
 
The services that are provided must meet the description of skilled therapy in this Coverage Determination. 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD), Outpatient Physical and Occupational Therapy Services, L33631. 
 
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 Medicare considers reduction mammaplasty reconstructive for gynecomastia. Mastectomy with 
nipple preservation or reduction mammoplasty is considered reconstructive and medically reasonable and 
necessary: 
 For males with unilateral or bilateral gynecomastia Grade III and IV as defined on the ASPS 
gynecomastia scale or abnormal breast development with redundancy. 
o Persists more than 3 to 4 months after pathological causes are ruled out. 
o Persists after 3 to 4 months of unsuccessful medical treatment for pathological 
gynecomastia. 
 Pain or tenderness directly related to the breast tissue which has a clinically significant impact 
upon activities of daily living. 
 Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents. 
 For significant clinical manifestations when the excessive breast weight adversely affects the 
supporting structures of the shoulders, neck, and trunk. 
You can find this in the Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery 
(L35090). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way routine transportation each year. You can find this information on page 4-57 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 60 one-way routine transportation trips per calendar year. You can find this information on page 4-
83 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 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. 
 
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 COVID-19 testing is covered when medically necessary and ordered by a physician. 
You can find this information on page 63 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 state that Current law permits the VA to collect appropriate Medicare coinsurance and deductible 
amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but 
furnished: 
 
    At VA facilities; and 
    For veterans eligible to receive both VA health and Medicare benefits and also having Medicare 
supplemental insurance. 
 
To facilitate this process, the Centers for Medicare & Medicaid Services (CMS) entered into an interagency 
agreement with the VA whereby CMS will help the VA work with the designated CMS contractor to adjudicate 
claims for these services to produce remittance advices equivalent to those ordinarily produced for Medicare 
claims. Medicare does not pay these claims, but the remittance advices show how much Medicare would have 
paid had the claims been payable by Medicare along with the applicable deductibles and coinsurance. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 37. 
 
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 as a member of the Plan, you usually will not acquire ownership of rented durable 
medical equipment items no matter how many copayments you make for the item while a member of the Plan. 
You can find this information on page 3-11 of the Plans 2022 Evidence of Coverage.  
 
The Plan contract says that enrollees must pay a 10% coinsurance for durable medical equipment. You can find 
this information on page 4-18 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 modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
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 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 health 
plan contract says that while you can get your care from an out-of-network provider, the provider must be 
eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out of 
or been excluded or precluded from the Medicare Program. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your 
provider before receiving services to confirm that they are eligible to participate in Medicare. You can find this 
information in Chapter 4 on page 3-4 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 under Section 1862(a)(2) of the Social Security Act (the Act), the Medicare program does not 
pay for services if the beneficiary has no legal obligation to pay for the services and no other person or 
organization has a legal obligation to provide or pay for that service. Also, under Section 1862(a)(3) of the Act, 
if services are paid for directly or indirectly by a governmental entity, Medicare does not pay for the services. 
These provisions are implemented by regulations 42 C.F.R. Section 411.4, 411.6, and 411.8, respectively. You 
can find this information in the Medicare Claims Processing Manual Chapter 1 - General Billing Requirements; 
10.4  Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody 
Under a Penal Authority. 
 
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 only the AS modifier must be reported on the claim when a NP or CNS bills assistant-at-
surgery services. You can find this information in the Medicare Claims Processing Manual Chapter 4 - Part B 
Hospital (Including Inpatient Hospital Part B and OPPS), Section 250.9.2 - Payment of Assistant at Surgery 
Services Rendered in a Method II CAH; Medicare Claims Processing Manual Chapter 12 - 
Physicians/Nonphysician Practitioners, Section 20.4.3- Assistant at Surgery Services; Section 120.1 - 
Limitations for Assistant-at Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists. 
 
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. 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL the following criteria:  
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity.  
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet 
ALL the following criteria: 
a. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with 
each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of 
relief being consistent with the agent used); AND 
b. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least consistent 50% 
pain relief for at least three (3) months from the prior therapeutic procedure 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; AND 
c. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established 
spinal pseudarthrosis, implanted electrical device) 
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L35936). 
 
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.