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  
A. Covered Indications Facet Joint Interventions: 
Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) Facet Joint Injections, 
Medial Branch Blocks (MBB), and Radiofrequency Ablations (RFA) and Facet cyst rupture/aspiration: 
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.  
* Pain assessment must be performed at baseline, after each diagnostic procedure using the same pain or 
disability scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment).  You can find this rule at Centers for Medicare and 
Medicaid Services, Local Coverage Determination (LCD) L38765, Facet Joint Interventions for Pain 
Management. 
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 self-help devices such as grab bars or precautionary items. You can 
find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 Medicare will pay for will not pay for equipment that is primarily and customarily used for 
nonmedical purposes or for equipment used for a patients comfort or for the convenience of a person caring 
for the patient. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say that a Medicare plan may not pay for services or equipment given by practitioner who has opted 
out of Medicare. 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.
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 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. 
 
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 enrollees must pay a $0 copayment  for lab services provided at a primary care physicians 
(PCP) office, specialists office, and a free standing laboratory. Additionally, enrollees must pay a $40 
copayment for lab services provided at an outpatient hospital. You can find this information on pages 62 and 65 
of the Plan's 2021 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 magnetic resonance image guided high intensity focused ultrasound (MRgFUS) is for the 
treatment of idiopathic essential tremor patients with medication-refractory tremor. 
Criteria for Medical Necessity: 
1. Essential tremor refractory to medical therapy, i.e., tremor refractory to at least two trials of medical 
therapy, which has included at least one first-line agent. 
2. Moderate to severe postural or intention tremor of the dominant hand [defined by a score greater than or 
equal to 2 on the Clinical Rating Scale for Tremor (CRST)]. 
3. Disabling essential tremor, i.e., a score of 2 or more on any of the eight items in the disability 
subsection of the CRST. 
4. Not a surgical candidate for deep brain stimulation. 
Exclusion from Coverage: 
1. Treatment of head or voice tremor 
2. Bilateral thalamotomy 
3. Following conditions:  
a. A neurodegenerative condition 
b. Unstable cardiac disease 
c. Coagulopathy 
d. Risk factors for deep-vein thrombosis 
e. Severe depression, i.e., a score greater than or equal to 20 on the Patient Health Questionnaire 9 
(PHQ-9) 
f. Cognitive impairment defined by a score of less than 24 on the Mini-Mental Status Examination 
g. Previous brain procedure (transcranial magnetic stimulation, deep brain stimulation, stereotactic 
lesioning, or electroconvulsive therapy) 
h. A skull density ratio (the ratio of cortical to cancellous bone) less than 0.45 
i. Contraindications for MRI.  
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
L35490, Category III Codes. 
 
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 effective for services performed on and after February 21, 2006, Open and laparoscopic 
Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch 
(BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who 
have a body-mass index = 35, have at least one co-morbidity related to obesity, and have been previously 
unsuccessful with medical treatment for obesity. These procedures are only covered when performed at 
facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center 
(program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society 
for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect 
on February 15, 2006). Effective for services performed on or after February 12, 2009, the Centers for 
Medicare & Medicaid Services (CMS) determines that Type 2 diabetes mellitus is a co-morbidity for purposes 
of this NCD. You can find this rule in the National Coverage Determination (NCD) - Bariatric Surgery for 
Treatment of Morbid Obesity (100.1) - Effective June 27, 2012. 
 
The rules say that the following bariatric surgery procedures are non-covered for all Medicare beneficiaries: 
 
-Open adjustable gastric banding; 
-Open and laparoscopic sleeve gastrectomy; and, 
-Open and laparoscopic vertical banded gastroplasty. 
 
You can find this rule in the National Coverage Determination (NCD) - Bariatric Surgery for Treatment of 
Morbid Obesity (100.1) - Effective June 27, 2012. 
 
The rules say that Medicare will cover stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of 
co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-
C are satisfied. 
 
1. The beneficiary has a body-mass index (BMI) = 35 kg/m2, 
2. The beneficiary has at least one co-morbidity related to obesity, and 
3. The beneficiary has been previously unsuccessful with medical treatment for obesity.  
You can find this rule in the Local Coverage Article (LCA) - Laparoscopic Sleeve Gastrectomy (LSG)  
Medical Policy Article (A52447) - Effective October 1, 2021. 
 
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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 160.7. 
 
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 enrollees must pay a $75 copayment for same day outpatient surgery in an outpatient hospital 
facility. You can find this information on page 94 of the Plan's 2021 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 $40 copayment per specialist visit. You can find this information in 
Chapter 4 on page 99 of the Plan's 2021 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay 20% coinsurance for Part B drugs, including chemotherapy 
drugs. You can find this information in Chapter 4 on page 87 of the Plan's 2021 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay 20% coinsurance for Medicare-covered durable medical 
equipment. You can find this information in Chapter 4 on page 70 of the Plan's 2021 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 all laboratory services furnished to individuals for the treatment of ESRD are included in 
the ESRD PPS as Part B services and are not paid separately as of January 1, 2011. This rule can be found in 
Chapter 11, Section 20.2 of the Medicare Benefit Policy Manual. 
 
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 Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be 
used on claims for evaluation and management (E/M) services, and only when these services are provided by 
the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another 
procedure or other service. 
 
Both the medically necessary E/M service and the procedure must be appropriately and sufficiently 
documented by the physician or qualified nonphysician practitioner in the patients medical record to support 
the claim for these services. 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 30.6.6. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 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 $275 copayment for Outpatient hospital services. You can find this 
information on pages 78 and 79 of the Plan's 2021 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 the Centers for Medicare & Medicaid Services has determined that extracorporeal 
photopheresis is reasonable and necessary under 1862(a)(1)(A) of the Social Security Act (the Act) under the 
following circumstances: 
 
1. Effective April 8, 1988, Medicare provides coverage for oalliative treatment of skin manifestations of 
cutaneous T-cell lymphoma that has not responded to other therapy. 
2. Effective December 19, 2006, Medicare also provides coverage for: 
 
-Patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug 
treatment; and, 
-Patients with chronic graft versus host disease whose disease is refractory to standard immunosuppressive 
drug treatment. 
 
3. Effective April 30, 2012, Medicare also provides coverage for extracorporeal photopheresis for the treatment 
of bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation only when extracorporeal 
photopheresis is provided under a clinical research study. 
 
You can find this rule in the National Coverage Determination (NCD) - Extracorporeal Photopheresis (110.4) - 
Effective April 30, 2021. 
 
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 enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. You can find 
this information on page 102 of the Plan's 2021 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 the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the 
treating physician before dispensing any DMEPOS item to a beneficiary. You can find this rule in the Centers 
for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-08, Medicare Program 
Integrity Manual, Chapter 5, Section 5.2.1. 
 
The rules say that the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) is required to maintain proof of delivery documentation in their files. You can find this rule in the 
Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-08, the Medicare 
Program Integrity Manual, Chapter 5, Section 5.2.1 
 
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.