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 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 on page 66 of the 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules say that PGx tests are indicated when medications are being considered for use (or already being 
administered) that are medically necessary, appropriate, and approved for use in the patients condition and are 
known to have a gene(s)-drug interaction that has been demonstrated to be clinically actionable as defined by 
the FDA (PGx information required for safe drug administration) or Clinical Pharmacogenetic Implementation 
Consortium (CPIC) guidelines (category A and B). 
The selection of the medications in question must be derived from clinical factors/necessity rather than from a 
PGx test. Once the putative therapeutic agents are selected, and those agents are known to have gene-drug 
interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of 
that test is necessary for the physicians decision-making process regarding safely administering or dosing the 
drug. 
PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular 
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to 
make a preliminary drug selection, PGx testing is not considered reasonable and necessary. You can find this 
rule at Local Coverage Determination (LCD) L38337: MolDX: Pharmacogenomics Testing (eff. 8/17/20). 
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 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, Section 3.3.2.1. 
 
The rules state that effective September 1, 1992, all laboratory testing sites (except as provided in 42 Code of 
Federal Regulations (CFR) 493.3(b)) must have either a Clinical Laboratory Improvement Amendments 
(CLIA) certificate of waiver, certificate for provider-performed microscopy procedures, certificate of 
registration, certificate of compliance, or certificate of accreditation to legally perform clinical laboratory 
testing on specimens from individuals in the United States. 
 
Effective with services provided October 1, 1997, any independent laboratory performing tests covered by 
CLIA must submit the CLIA number on the claim. Laboratory claims submitted without the required CLIA 
number are returned as unprocessable. If the CLIA number is submitted on the claim, but is inconsistent with 
the CLIA format, the A/B MAC (B) returns the claim as unprocessable. If more than one CLIA number is 
submitted on the claim, except when a reference laboratory is on the same claim, the A/B MAC (B) returns the 
claim as unprocessable. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 70. 
 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 417.414. 
The rules say that Polyethylene-glycol (PEG) hydrogel is covered ONCE in patients with clinically localized 
prostate cancer with BOTH the following:  
1. Inclusion criteria including ALL of the following:  
a. Low* or Favorable Intermediate Prostate Cancer Risk Group (1-5) (AUA or NCCN criteria 
(6,7)) 
b. Dose escalated ( 76 Gy) conventional fractionation (1.8-2 Gy fractions) or moderate 
hypofractionation (HFX) (2.4-3.4 Gy fractions) IG-IMRT planned (7,8,9,25-27) 
c. Eastern Cooperative Oncology Group (ECOG) performance status  1 (4) 
d. Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side 
effects due to AT LEAST ONE of the following (7):  
i. Anatomic geometry precluding ideal rectal constraints   
o Conventional fractionation (V70 <10%, V65 <20%, V40 <40%) (10) 
o Moderate HPX (dose constraints not yet standardized; employ those used in the 
supporting phase III trials) (25) 
ii. Medication usage (e.g., anticoagulants) (8,11,12) 
iii. Comorbid conditions (e.g., increased age, Hx MI or CHF) (11) 
2. No Exclusion criteria including ALL of the following:  
a. Less than 5 year life-expectancy and asymptomatic (7) 
b. Prior prostate cancer treatment (surgery or RT) (1,3,4,8) 
c. Active bleeding disorder or clinically significant coagulopathy (8) 
d. Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, 
anorectal IBD) (1,3,8) 
e. Prostate volume > 80 cc (1,3,4) 
*Life expectancy  20 y (very low risk);  10 y (low risk) (7) 
Prostate rectal spacers are various materials or devices placed between the prostate and anterior wall of the 
rectum for use in men receiving radiation therapy for prostate cancer. The anterior wall of the rectum is considered a major dose-limiting factor in radiation therapy of prostate cancer. Physical separation is proposed 
to allow reduced toxicity and treatment intensification. You can find this rule at Local Coverage Determination 
(LCD) L37485: Prostate Rectal Spacers (eff. 8/1/20). 
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 on pages 106 and 107 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
 
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has  
    sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use;  
    and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the     
     criteria below: 
     A. The beneficiary is insulin-treated; or, 
     B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the   
          following: 
          -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
                medication(s) and/or modify the diabetes treatment plan; or, 
          -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state  
                requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare- 
     approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria  
     (1)-(4) above are met.  
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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).  
 
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 there is a $800 deductible which applies to certain items and services. The Plan 
deductible applies to the out-of-network physician service. You can find this information on page 45 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 state that to receive payment for Medicare-covered items or services from either Medicare or a 
Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program. You can find this rule 
in 42 Code of Federal Regulations (CFR) Section 424.505. 
 
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 we cover medically necessary DME covered by Original Medicare. If our supplier in your 
area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you. 
You can find this information on pages 61 to 62 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers.  You can find this information on page(s) 62-66 of the Plan's 
2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of knee. This information is 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 state that generally, items and services provided outside of the United States (US) are not covered. 
The only exceptions are emergency hospital services when the emergency occurred within the US, 
emergency/non-emergency hospital services when the foreign hospital is substantially closer or more 
accessible than the US hospital, or services provided on a ship docked at a US port or within US Territorial 
waters. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60. 
 
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 routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose 
of prescribing, fitting, or changing eyeglasses; eye refractions by whatever practitioner and for whatever 
purpose performed; hearing aids and examinations for hearing aids; and immunizations are not covered.  
 
The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment 
or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties 
such as insurance companies, business establishments, or Government agencies. 
 
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 39 to 40 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 state that amendments or delayed entries to paper records must be clearly signed and dated upon 
entry into the record. Amendments or delayed entries to paper records may be initialed and dated if the medical 
record contains evidence associating the provider's initials with their name. For example, if the initials match 
the first and last name of the practitioner documented elsewhere in the medical records including typed or 
written identifying information, the reviewer shall accept the entry. 
 
Electronic Health Records (EHR): Medical record keeping within an EHR deserves special considerations; 
however, the principles specified above remain fundamental and necessary for document submission to MACs, 
CERT, Recovery Auditors, SMRC and UPICs. Records sourced from electronic systems containing 
amendments, corrections or delayed entries must: 
 
    a. Distinctly identify any amendment, correction or delayed entry, and; 
 
    b. Provide a reliable means to clearly identify the original content, the modified content, and the date and 
authorship of each modification of the record. 
 
    c. If the MACs, CERT, SMRC or Recovery Auditors identify medical documentation with potentially 
fraudulent entries, the reviewers shall refer the cases to the UPIC and may consider referring to the RO and 
State Agency. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Program Integrity Manual, Chapter 3, Section 3.3.2.5. 
 
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.