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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules say that for DMEPOS items and supplies provided on a recurring basis, billing must be based on 
prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, 
suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-
determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item 
remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or 
modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner 
than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the 
DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is 
regardless of which delivery method is utilized. 
 
For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the 
beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills 
without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be 
denied as not reasonable and necessary. You can find this rule in 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 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 page 8 of the 2023 Evidence 
of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
Medicare rules say that screening prostate specific antigen tests are covered at a frequency of once every 12 
months for men who have attained age 50 (at least 11 months have passed following the month in which the 
last Medicare-covered screening prostate specific antigen test was performed). Screening prostate specific 
antigen tests (PSA) means a test to detect the marker for adenocarcinoma of prostate. PSA is a reliable 
immunocytochemical marker for primary and metastatic adenocarcinoma of prostate. This screening must be 
ordered by the beneficiary's physician or by the beneficiary's physician assistant, nurse practitioner, clinical 
nurse specialist, or certified nurse midwife who is fully knowledgeable about the beneficiary's medical 
condition, and who would be responsible for using the results of any examination (test) performed in the 
overall management of the beneficiary's specific medical problem. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-3, National Coverage 
Determinations (NCD) Manual: Prostate Cancer Screening Tests (NCD 210.1). 
 
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 state that left prefrontal transcranial magnetic stimulation (TMS) of the brain is considered medically 
necessary for use in an adult who meets the following criteria:  
 
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) (single or recurrent episode); AND  
2. One or more of the following: The patient has demonstrated resistance to treatment with 
psychopharmacologic agents as evidenced by a lack of clinically significant response to four trials of such 
agents, in the current depressive episode, from at least two different agent classes. (At least one of the treatment 
trials must have been administered as an adequate course of mono- or poly-drug therapy; antidepressants 
involving standard therapeutic doses of at least 4 weeks duration); or Inability to tolerate psychopharmacologic 
agents as evidenced by four trials of psychopharmacologic agents with distinct side effects; or History of 
response to TMS in a previous depressive episode; (evidenced by a greater than 50% improvement in a 
standard rating scale for depression symptoms); or Is currently receiving or is a candidate for and has declined 
electroconvulsive therapy (ECT) and TMS is considered a less invasive treatment option; AND  
3. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate 
frequency and duration without significant improvement in depressive symptoms as documented by 
standardized rating scales that reliably measure depressive symptoms. 
 
This information is found in Local Coverage Determination (LCD): Transcranial Magnetic Stimulation for 
Major Depressive Disorder (L34522). 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical 
of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 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 state that the reasonable useful lifetime of durable medical equipment is determined through program 
instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful 
lifetime of equipment, but in no case can it be less than five years. You can find this rule in the Centers for 
Medicare & Medicaid Services, Medicare Benefit Policy Manual- Chapter 15, Section 110.2. 
 
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. 
Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services 
(CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable 
and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; 
and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to 
specify treatment options. 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations Manual, Section 90.2. 
 
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 polyethylene-glycol (PEG) hydrogel is covered once in patients with clinically localized 
prostate cancer with both the following:  
 
    Inclusion criteria including ALL of the following: 
        Low* or Favorable Intermediate Prostate Cancer Risk Group (1-5) (AUA or NCCN criteria (6,7)) 
        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) 
        Eastern Cooperative Oncology Group (ECOG) performance status = 1 (4) 
        Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side effects due 
to at least one of the following (7): 
            Anatomic geometry precluding ideal rectal constraints  
                Conventional fractionation (V70 <10%, V65 <20%, V40 <40%) (10) 
                Moderate HPX (dose constraints not yet standardized; employ those used in the supporting phase III 
trials) (25) 
            Medication usage (e.g., anticoagulants) (8,11,12) 
            Comorbid conditions (e.g., increased age, Hx MI or CHF) (11) 
    No Exclusion criteria including ALL of the following: 
        Less than 5 year life-expectancy and asymptomatic (7) 
        Prior prostate cancer treatment (surgery or RT) (1,3,4,8) 
        Active bleeding disorder or clinically significant coagulopathy (8) 
        Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, anorectal 
IBD) (1,3,8) 
        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 these rules in the Local Coverage Determination (LCD) Prostate Rectal Spacers L37485. 
 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 page 62 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 state that HBB gene testing may be performed during the diagnosis of Sickle cell disease (SCD). 
Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a 
covered benefit, the MolDX Team has determined HBB gene testing is a statutorily excluded service. MolDX 
will also deny panels of tests that include the HBB gene. You can find this information in the Centers for 
Medicare and Medicaid Services, Local Coverage Article (LCA): Billing and Coding: MolDX: HBB Gene 
Tests (A55254). 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that an axial rotation unit (L5986) is covered for beneficiaries whose functional level is 3 or 
above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020. 
 
The rules say that a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
3. The beneficiarys desire to ambulate. 
You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 1, 2020. 
 
The rules say that a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical 
of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 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. 
 
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 copayment for Outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page(s) 77 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 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 $300 copayment per day, days 1-5, and a $0 copayment per day, days 6-
90, for each in-network Medicare-covered hospital stay. You can find this information on page 54 of the Plan's 
2022 Evidence of Coverage (EOC).