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 Various Hyaluronan preparations (viscosupplementation) for intra-articular injections of the 
knee are considered reasonable and necessary when ALL of the following criteria documented in the medical 
record are met: 
  
   
1. Symptomatic osteoarthritis of the knee. Pain that interferes with functional activities (such as, ambulation 
and prolonged standing). 
2. The diagnosis is supported by radiographic evidence of osteoarthritis of the knee, for example, joint space 
narrowing, subchondral sclerosis, osteophytes, and subchondral cysts. 
3. Trial and failure or contraindication of at least 3 months of conservative therapy: including Non-
pharmacologic therapy (e.g., physical therapy, exercise, weight management, self-management programs, knee 
brace, cane) and Pharmacologic therapy (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) 
(oral, topical), topical capsaicin). 
4. Failure of or contraindication to intra-articular glucocorticoid injections. 
 
These rules are found in Local Coverage Determination (LCD): Hyaluronic Acid Injections for Knee 
Osteoarthritis (L39260). 
 
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 powered knee prosthesis (L5859) is covered when the following criteria are met: 
 
1. The enrollee has a microprocessor (swing and stance phase type (L5856) controlled (electronic) knee. 
2. The enrollee has K3 functional level only. 
3. The enrollee 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. The enrollee is able to make use of a product that requires daily charging. 
5. The enrollee is able to understand and respond to error alerts and alarms indicating problems with the 
function of the unit 
 
These rules are found 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 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 in Chapter 4 on pages 71 to 72 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 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 
periodontal scaling and root planing services once per quadrant every three calendar years. You can find this 
information on pages 56-58 of the Plans 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 state that if a positive airway pressure (PAP) device is replaced following the 5 year reasonable 
useful lifetime (RUL), there must be an in-person evaluation by their treating practitioner that documents that 
the beneficiary continues to use and benefit from the PAP device. You can find this information in the Local 
Coverage Determination (LCD) Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive 
Sleep Apnea L33718. 
 
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 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 the 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.
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 this section applies to psychiatric services rendered in a hospital outpatient facility, but the 
medical necessity parameters contained herein may also be applicable to services billed to Part B by individual 
providers. 
 
Hospital outpatient psychiatric services:  The services must be for the purpose of diagnostic study or the 
services must reasonably be expected to improve the patient's condition. "Incident to" provisions do not apply 
to professional services performed by Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Clinical 
Psychologists (CPs), Clinical Social Workers (CSWs) or Clinical Licensed Master's Social Worker (LMSW). 
Physician assistants (PAs) are required to perform services under the general supervision of a physician. (See 
42 CFR 410.71-76.) Psychiatric services provided incident to a physician's service must be rendered by 
individuals licensed or otherwise authorized by the State and qualified by their training to perform these 
services. 
 
Coverage Criteria. 
 
The services must meet the following criteria: 
 
Individualized Treatment Plan. 
 
The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the 
diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.) 
 
Reasonable Expectation of Improvement. 
 
Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's 
condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric 
symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient's level of functioning. 
 
When stability can be maintained without further treatment or with less intensive treatment, the psychological services are no longer medically necessary. 
 
Frequency and Duration of Services. 
 
There are no specific limits on the length of time that services may be covered. There are many factors that 
affect the outcome of treatment; among them are the nature of the illness, prior history, the goals of treatment, 
and the patient's response. As long as the evidence shows that the patient continues to show improvement in 
accordance with his/her individualized treatment plan, and the frequency of services is within accepted norms 
of medical practice, coverage may be continued. 
 
When a patient reaches a point in his/her treatment where further improvement does not appear to be indicated 
and there is no reasonable expectation of improvement, the outpatient psychiatric services are no longer 
considered reasonable or medically necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Psychiatry and Psychology Services 
L33632. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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 there is a Point-of-Service (POS) option to cover certain out-of-network services. While the 
enrollee can get care from an out-of-network provider, the provider must be eligible to participate in Medicare. 
Certain covered services may only be received from network providers. You can find this information on page 
3-4 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that out-of-network vision services are not covered. You can find this information 
on pages 4-86 to 4-88 of the Plan's 2022 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
  
  
  The rules say that a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 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 thatIn addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain 
other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment 
basis, A/B MACs (B) identify the services that meet the following conditions: 
-Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; 
or 
-Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical 
procedure or endoscopy; and - 
-Services that were furnished within the prescribed global period of the surgical procedure; 
-Services that are billed without modifier -78, -79, -24, 25, or -57 or are billed with modifier -24 
but without the required documentation; and 
-Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, 
edit for any visits billed separately during the postoperative period without modifier -24 by a physician who 
billed for the postoperative care only with modifier -55. 
 
The rules also say that if a surgeon is admitting a patient to a nursing facility for a condition not related to the 
global surgical procedure, the physician should bill for the nursing facility admission and care with a -24 
modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the 
patients admission to that facility relates to the global surgical procedure, the nursing facility admission and 
any services related to the global surgical procedure are included in the global surgery fee. 
You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Section 40.3. 
 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.
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 pages 6 to 7of 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 state that there is a list of diagnosis codes that support medical necessity and provide coverage for 
code 88189. 
Any diagnosis code not listed under the ICD-10 Codes that Support Medical Necessity section of this article 
do not support medical necessity of code 88189. 
You can find this rule in the Local Coverage Article Billing and Coding: Flow Cytometry, A57716. 
 
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 epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following 3 requirements are met: 
1. History, physical examination, and concordant radiological image-based diagnostic testing and 
supporting 1 of the following: 
- Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis; 
- Post-laminectomy syndrome 
- Acute herpes zoster associated pain 
2. 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 repeated at each follow-up for assessment of response. 
3. Pain duration of at least 4 weeks, and the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to 4 weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a 4-week wait is not required. 
 
You can find these rules in Local Coverage Determination (LCD) Epidural Steroid Injections for Pain 
Management (L39242). 
 
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.