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 coverage for BOtox will only be allowed for those patients chronic daily headaches 
(headache disorders occurring greater than 15 days a month - in many cases daily with a duration of four or 
more hours - for a period of at least 3 months) who have significant disability due to the headaches, and have 
been refractory to standard and usual conventional therapy. The etiology of the chronic daily headache may be 
chronic tension-type headache or chronic migraine (CM). CM is characterized by headache on greater than or 
equal to 15 days per month, of which at least 8 headache days per month meet criteria for migraine without 
aura or respond to migraine-specific treatment. For continuing Botulism toxin therapy the patients must 
demonstrate a significant decrease in the number and frequency of headaches and an improvement in function 
upon receiving Botulinum toxin. You can find this rule at Local Coverage Determination (LCD) L33949: 
Botulinum Toxins (eff. 11/25/21). 
 
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 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. 
 
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 that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial 
branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) 
medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% 
sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
 
Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary 
provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months 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. 
 
One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or 
four-level procedure bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., 
MBB, IA, facet cyst ruptures, and RFA ablations) that are performed during the same day. You can find this 
rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management, L33930. 
 
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 repetitive transcranial magnetic stimulation (rTMS) is only considered medically necessary 
in adults who have a confirmed diagnosis of major depressive disorder (MDD), single or recurrent episode and 
meet the following criteria: 
 Resistance to treatment as evidenced by a lack of a clinically significant response to four (4) trials of 
psychopharmacologic agents in the current depressive episode; 
o Two different agent classes, at or above the minimum effective dose and duration and includes 
trials of at least two (2) evidence-based augmentation therapies; or 
 Inability to tolerate psychopharmacologic agents as evidenced by four (4) trials of 
psychopharmacologic agents with distinct side effects; or  
 History of response to rTMS in a previous depressive episode; or 
 History of response to electroconvulsive therapy (ECT) in a previous or current MDD episode, or 
inability to tolerate ECT, and rTMS is considered a less invasive treatment option; and 
 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 
 The rTMS treatment is delivered by a device that is FDA-approved or cleared for the treatment of 
MDD in a safe and effective manner. rTMS treatment should generally follow the protocol and 
parameters specified in the manufacturers user manual, with modifications only as supported by the 
published scientific evidence base; and  
 The order for treatment (or retreatment) is written by a physician (MD or DO) who has examined the 
patient and reviewed the record. The physician must have experience in administering rTMS therapy 
and the treatment must be given under direct supervision of this physician, i.e., he or she must be in the 
area and be immediately available. 
You can find this information in Local Coverage Determination (LCD): Transcranial Magnetic Stimulation 
(TMS) (L33398). 
 
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 that The DOS policy for either a clinical laboratory test or the technical component of physician 
pathology service is as follows:  
 
General Rule: The DOS of the test/service must be the date the specimen was collected. 
Variation: If a specimen is collected over a period that spans two calendar days, then the DOS must be the 
date the collection ended. 
 
Exceptions: The following three exceptions apply to the DOS policy for either a clinical laboratory test or 
the technical component of physician pathology service: 
A. DOS for Tests/Services Performed on Stored Specimens: 
In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal 
to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the 
test/service was performed only if: 
 
 The test/service is ordered by the patients physician at least 14 days following the date of the 
patients discharge from the hospital; 
 The specimen was collected while the patient was undergoing a hospital surgical procedure; 
 It would be medically inappropriate to have collected the sample other than during the hospital 
procedure for which the patient was admitted; 
 The results of the test/service do not guide treatment provided during the hospital stay; and 
 The test/service was reasonable and medically necessary for treatment of an illness. 
 If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have 
been archived and the DOS of the test/service must be the date the specimen was obtained from storage. You 
can find this rule in Medicare Claims Processing Manual. Chapter 16-Laboratory services. 
 
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 the Decipher Prostate Cancer Classifier Assay is considered reasonable and necessary to 
help identify men with localized Prostate Cancer and a life expectancy of at least 10 years who are good 
candidates for active surveillance according to the most recent National Comprehensive Cancer Network 
(NCCN) guidelines.  
 
Decipher is covered for men with prostate cancer with localized or biochemically recurrent adenocarcinoma 
of the prostate (i.e., no clinical evidence of metastasis) who have a life expectancy of greater than or equal to 
10 years if they are a candidate and are considering (or being considered for) at least 1 of the following: 
Conservative management and yet would be eligible for definitive therapy (radical prostatectomy (RP), 
radiation or brachytherapy), or; 
Radiation therapy and yet would be eligible for the addition of a brachytherapy boost, or; 
Radiation therapy and yet would be eligible for the addition of short-term androgen deprivation therapy (ADT), 
or; 
Radiation therapy with short-term ADT yet would be eligible for the use of long-term ADT, or; 
Radiation with standard ADT yet would be eligible for systemic therapy intensification using next generation 
androgen signaling inhibitors or chemotherapy, or; 
Observation post-prostatectomy yet would be eligible for the addition of post-operative adjuvant radiotherapy, 
or; 
Salvage radiotherapy post-prostatectomy yet would be eligible for the addition of ADT. 
 
You ca find this information in Local Coverage Determination (LCD): MolDX: Prostate Cancer Genomic 
Classifier Assay for Men with Localized Disease (L38339). 
 
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 treatment for lower urinary tract symptoms/benign prostatic hyperplasia treatment will be 
considered reasonable and necessary when performed ONCE in patients with the following: 
 
1. Indications including ALL of the following: 
 
a. Age less than 80 
b. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
c. Persistent moderate to severe symptoms despite maximal medical management including ALL of the 
following: 
 
i. International Prostate Symptom Score (IPSS) =124 
ii. Maximum urinary flow rate (Qmax) of =15 mL/s4 (voided volume greater than 125 cc) 
iii. Failure, contraindication or intolerance to at least 3 months of conventional medical therapy for LUTS/BPH 
(e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination (LCD) - Transurethral Waterjet Ablation of the 
Prostate (L38549) - Effective December 27, 2020. 
 
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 CPT codes describing anesthesia services (00100-01999) or services that are bundled into 
anesthesia should not be reported in addition to the surgical or medical procedure requiring the anesthesia 
services if performed by the same physician. You can find this rule in the National Correct Coding Initiative 
Policy Manual, Chapter I. 
 
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 a Medicare plan may restrict enrollees 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 specialty care outside of the plan provider network when network providers are unavailable or 
inadequate to meet an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 45 to 46 of the Plan's 
2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a knee orthosis with with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843) is covered if the beneficiary has had recent injury to or a surgical procedure 
on the knee(s). L1843 is also covered for a beneficiary who is ambulatory and has knee instability. For code 
L1843, knee instability must be documented by examination of the beneficiary and objective description of 
joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims for L1843 will be denied as 
not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, 
they will be denied if only pain or a subjective description of joint instability is documented. You can find this 
rule in Local Coverage Determination (LCD): Knee Orthoses (L33318) - Effective January 1, 2020. 
 
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. 
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 Plan 
contract says that enrollees must pay a $225 copayment for each Medicare-covered outpatient hospital facility 
visit. You can find this information on page 105 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 also say that providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-
T9, E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims 
Processing Manual, Chapter 23, Section 20.9.3.2. 
 
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 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 each Medicare-covered hospital stay each time you 
are admitted. You can find this information on page 4-33 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 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).   
 
The rules say subluxation may be shown by x-ray or physical exam. 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 240.1.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.