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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 34 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 Medicare has reaffirmed non-coverage for codes 0012M and 0013M for CxBladder.  You 
can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L35396 
entitled Biomarkers for Oncology. 
 
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 cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 
and 2 above and either criterion A, B or C below has been met: 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received 
treatment for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that 
a chin halter is unable to be utilized; or, 
C. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will 
be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD) 
Cervical Traction Devices L33823. 
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 therapeutic embolization is covered when done for hemorrhage, and for other conditions 
amenable to treatment by the procedure, when reasonable and necessary for the individual patient. Renal 
embolization for the treatment of renal adenocarcinoma continues to be covered, effective December 15, 1978, 
as one type of therapeutic embolization, to: 
 Reduce tumor vascularity preoperatively; 
 Reduce tumor bulk in inoperable cases; or 
 Palliate specific symptoms. 
You can find this information in the National Coverage Determination (NCD) Therapeutic Embolization 20.28. 
 
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 UV light therapy systems are covered for selected patients with generalized intractable psoriasis. Using appropriate consultation, the MAC should determine whether medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of a hospital. You can find this information in the National Coverage Determination (NCD) Durable Medical Equipment Reference List 280.1.
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.
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 procedure codes L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features
and/or functions that do not describe a complete prosthetic foot and may be used in combination with L5970,
L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The use of additional feature
L-codes may also depend on the assigned K-Level modifier (K0-K4). You can find this information in Local
Coverage Article: Lower Limb Prostheses (A52496).
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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when ALL of the following are true: 
1. The patient has a personal history of melanoma AND:  
a. Either:  
i. Has Stage T1b and above OR 
ii. Has T1a with documented concern about adequacy of microstaging 
b. Is undergoing workup or being evaluated for treatment, AND 
c. Does not have metastatic disease AND 
d. Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, 
histological, or other information is >5% AND 
e. Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the 
intended use of the test. 
You can find this rule in Local Coverage Determination (LCD) MolDX: Melanoma Risk Stratification 
Molecular Testing L38018. 
 
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).
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 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. You can find this information on page 22 and 57 of the Plan's 2023.
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 and cover any medically necessary covered benefit of the plan provider network, but at in-network
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii).
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 10 of the Plans 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $150 copayment for outpatient diagnostic tests. You can find this 
information on page(s) 70 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 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).  
 
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 there is a $1000 deductible which applies to certain items and services. The Plan deductible 
applies to outpatient surgery services. You can find this information on pages 53 and 54 of the Plan's 2023 
Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $200 copayment per day, after the deductible, for other in-
network outpatient procedures and services, including, but not limited to, diagnostic and therapeutic 
endoscopy, and outpatient surgery performed in an ambulatory surgical center. You can find this information 
on pages 106 and 107 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and
(b).
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that enrollees must pay a $90 copayment for emergency care. You can find this information on
page 78 of the Plan's 2022 Evidence of Coverage (EOC).
The Plan contract says there is a $275 copayment for advanced imaging provided in an outpatient facility. You
can see this on page 93 of the Plans 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
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 the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. Additionally, enrollees pay 10% of the total cost for each Medicare-covered durable medical 
equipment item. You can find this information on pages 6 and 9 of the Plans 2023 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 state that percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with BOTH the following: 
1. Inclusion criteria (ALL are required): 
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5), based on 
symptom onset, and documented by advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake)  
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score greater than or equal to 8) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) 
despite optimal non-surgical management (NSM) (10) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with 
Greater than or equal to 2 of the following): 
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (Both)  
i. All patients presenting with VCF should be referred for evaluation of BMD and 
osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have NONE of the following):   
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection iii. Pregnancy 
b. Relative contraindication 
I. Greater than three vertebral fractures per procedure 
II. Allergy to bone cement or opacification agents 
III. Uncorrected coagulopathy 
IV. Spinal instability 
V. Myelopathy from the fracture 
VI. Neurologic deficit 
VII. Neural impingement 
VIII. Fracture retropulsion/canal compromise 
You can find this rule in the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF), L33569. 
 
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 certain items of durable medical equipment can only be rented, and not purchased. The 
Durable Medical Equipment Coding System (DMECS) states that K0012- lightweight portable 
motorized/power wheelchair  is considered a capped rental item. This item may only be rented. You can find 
this rule in the Pricing, Data Analysis and Coding (PDAC) DMECS. 
 
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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aid benefit is limited to 2 hearing aids every year. The Plan contract also says 
that hearing aids purchased outside of the Plan hearing network are not covered. You can find this information 
on page 4-23 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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 30% coinsurance for out-of-network outpatient surgery, including 
services provided at ambulatory surgical centers. You can find this information on page(s) 50 to 51 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 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 ZIP Code of the point of pickup (POP) must be reported on each claim for ambulance 
services so that the correct Geographic Adjustment Factor (GAF) and Rural Adjustment Factor (RAF) may be 
applied, as appropriate. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 10.3. 
 
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.