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 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 health 
plan contract says that they have a link will take you to a list of Part B Drugs that may be subject to Step 
Therapy. You can find this information in Chapter 4 on page 71 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 the primary indication of a diagnostic facet joint procedure is to diagnose whether the patient 
has facet syndrome. Intraarticular (IA) facet block(s) are considered medically reasonable and necessary as a 
diagnostic test only if MBB cannot be performed due to specific documented anatomic restrictions or there is 
an indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly 
documented in the medical record and made available upon request. 
 
Diagnostic procedures should be performed with the intent that if successful, a RFA procedure would be 
considered the primary treatment goal at the diagnosed level(s). 
 
A second diagnostic facet procedure is considered medically reasonable and necessary to confirm validity of 
the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure. 
 
        An initial diagnostic facet joint procedure will be considered medically reasonable and necessary when the 
patient meets the criteria outlined under the indications for facet joint interventions. 
        A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary 
in patients who meet BOTH of the following criteria: 
            The patient meets the criteria for the first diagnostic procedure; AND 
            After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 
80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
 
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be 
considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator 
cannot always be identified with the initial and confirmatory diagnostic procedure. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L34892). 
 
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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. 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 290(3). 
 
The rules say inserts and other shoe modifications (L3020) are covered if they are on a shoe that is an integral 
part of a covered brace and if they are medically necessary for the proper functioning of the brace. 
 
With the exception of the situations described above, orthopedic footwear billed using code L3020 will be 
denied as non-covered. 
 
You can find this rule in the Local Coverage Article: Orthopedic Footwear - Policy Article (A52481). 
 
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 Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determinations Manual, Chapter 1, Section 310.1. 
 
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. The Plan 
contract also says that a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the 
Plan. You can find this information on pages on pages 3-8 to 3-9 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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
 
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 non-emergency transportation by ambulance is appropriate if it is documented that the 
member's condition is such that other means of transportation could endanger the person's health and that 
transportation by ambulance is medically required. You can find this information on page 75 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 effective January 18, 2017, the Centers for Medicare & Medicaid Services (CMS) covers leadless 
pacemakers through Coverage with Evidence Development (CED). CMS covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, in 
prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA approved label 
for devices that have either: 
 an associated ongoing FDA approved post-approval study; or 
 completed an FDA post-approval study. 
 
Each study must be approved by CMS and as a fully-described, written part of its protocol, must address the 
following research questions: 
 What are the peri-procedural and post-procedural complications of leadless pacemakers? 
 What are the long term outcomes of leadless pacemakers? 
 What are the effects of patient characteristics (age, gender, comorbidities) on the use and health effects of 
leadless pacemakers? 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, National Coverage Determination Manual Chapter 1, Section 20.8.4. 
 
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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, 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 40-48 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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(A). 
 
The rules state that the limitations for a cardiac computed tomographic angiography (CCTA) include: 
 
1. Coverage of CCTA is limited to computed tomography (CT) devices that process thin, high resolution slices. 
Decreased resolution and slower rotation speeds result in a higher number of non-evaluable segments. At the 
current time, Medicare requires the multidetector scanner to have collimation of 0.625 mm or less and a 
rotational speed of 375 msec or less OR to have at least 64 slice detector design. Do not submit studies from 
scanners that do not meet these requirements. 
 
2. Medicare does not cover a screening CCTA for asymptomatic patients, for risk stratification or for 
quantitative evaluation of coronary calcium. This Local Coverage Determination (LCD) does not address 
Heartflow determinations. 
 
Ultrafast CT scan of the heart electron-beam tomography (EBT) or electron-beam computed tomography 
(EBCT) is not a covered service. 
 
3. Simultaneous exclusion of obstructive coronary artery disease (CAD), pulmonary embolism and aortic 
dissection (triple rule-out) in the emergency department is not covered. In order to optimize imaging of the 
right coronary artery (RCA), contrast must be cleared from the right sided chambers during acquisition, a 
process that leads to suboptimal contrast timing in the pulmonary arteries. Simultaneous rule-out of aortic 
pathology (at the low pitch needed to properly image the coronaries) mandates thicker slices in order to capture 
the total volume required in a reasonable breath hold. The increased slice thickness degrades coronary image 
quality. 
 
4.  CCTA patients must be able to lie still, follow breathing instructions and take nitroglycerin for coronary 
dilatation. 
 
 
 5. Prior to the initiation of a CCTA, the physician must make an assessment of the anatomic location, degree 
and intensity of calcification and impact of the calcification on the utility of the test results.  CCTAs performed 
on patients with elevated quantitative calcium scores that preclude accurate assessment of coronary anatomy 
are not covered by Medicare. 
 
You can find this information in the Local Coverage Determination (LCD): Cardiac Computed Tomography & 
Angiography (CCTA) (L33423). 
 
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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
1. Initial thermal RFA: 
i. After the patient has 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) AND 
ii. 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 
You can find this rule at Local Coverage Determination (LCD) L38801: Facet Joint Interventions for Pain 
Management (eff. 2/3/22). 
 
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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)):  
1. The MA plan provides all categories of DME covered under original Medicare Part B;  
2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands;  
3. The MA plans contracted suppliers provide access to all preferred DME brands;  
4. During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year;  
5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year;  
6. The MA plan treats denials of non-preferred DME products or brands as organization determinations;  
7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the EOC and ANOC and on its website; and  
8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage.  
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, 
Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
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. 
 
Medicare rules say that the provider must notify the enrollee in writing before it ends coverage of home health 
services. A Notice of Medicare Non-Coverage (NOMNC) must be issued no later than two days before the last 
covered day.  
  
  If the span of time between services exceeds two days, the notice should be given no later than the next to last 
time services are furnished. The notice must include: 
 
1. The date that coverage of service ends; 
2. The date the enrollee becomes responsible to pay for the service; and 
3. A description of the enrollees right to a fast-track appeal and other appeal procedures. You can find this rule 
at 42 CFR Section 422.624(b).  
 
A Health Plan is financially liable for continued services until two days after the enrollee receives valid notice. 
You can find this rule at 42 CFR Section 422.624(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.
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 implantable loop recorder (ILR) is implanted subcutaneously in a patients upper left 
chest and may remain implanted for many months. An ILR is used when syncope is thought to be cardiac-
related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom memory 
loop recorder. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determination (NCD) - Electrocardiographic Services (20.15) - 
Effective August 26, 2004. 
 
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). 
 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist,  
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary when the fracture in question 
is less than 12 weeks old. You can find more information in Local Coverage Determination (LCD): 
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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.