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 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). 
 
The rules say that abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the 
abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, 
chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, and the above symptoms 
have been present for at least three months and are refractory to usual standard medical therapy, such surgery 
may be considered reconstructive. Preoperative photographs may be required to support justification and 
should be supplied upon request. 
 
You can find more information in Local Coverage Determination (LCD): Plastic Surgery (L35163). 
 
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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(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. The Plan 
contract says that you may receive hearing services from any network hearing aid provider. You can find this 
information on page 84 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 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). 
 
Non-invasive vascular studies are considered medically necessary if the ordering physician has reasonable 
expectation that their outcomes will potentially impact the clinical management of the patient. Services are 
deemed medically necessary when the following conditions are met: 
1. Significant signs/symptoms of arterial or venous disease are present; and/or 
2. The information is necessary for appropriate medical and/or surgical management; and/or 
3. The test is not redundant of other diagnostic procedures that must be performed. 
 
In general, non-invasive studies of the arterial system are utilized when invasive correction is contemplated or 
when vessels are being harvested for potential use as grafts. It is the responsibility of the physician/provider to 
ensure the medical necessity of procedures and documentation of such in the medical record. You can find this 
information in the Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Non-
Invasive Vascular Studies (L33627). 
 
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 in Chapter 3 on page 45 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 20% coinsurance for all other Medicare-covered Part B drugs. You can 
find this information on pages 4-37 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $20 copayment for Medicare-covered non-radiological 
diagnostic services, a $110 copayment for Medicare-covered radiological diagnostic services, not including x-
rays, and 20% coinsurance for each Medicare-covered medical supply. You can find this information on pages 
4-43 to 4-46 of the Plan's 2022 EOC. 
 
The Plan contract also says that enrollees must pay a $35 copayment for services obtained from a specialist. 
You can find this information on page 4-58 of the Plan's 2022 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 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 in on pages 3-3 to 3-4 of the 
Plans 2021 EOC.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay $295 copayment for Outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers. You can find this information in chapter 4 on 
pages 82 to 83 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 state that the sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular 
surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to 
the development of strain and/or pain. 
 
Indications for Sacroiliac (SI) Joint Injections: 
 
Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis 
and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint 
dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless 
conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. 
 
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. 
Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by 
the intra-articular injection of a small volume of local anesthetics of different durations of actions. A positive 
response should demonstrate initial pain relief greater than or equal to (> /=) 75% - 100% and the ability to 
perform previously painful maneuvers. Steroids may be injected in addition to the local anesthetic. 
 
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and 
potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that 
the SI joint is the source of pain in the lower back. The local anesthetic used for the procedure should not be 
billed. 
 
SI joint arthrography and/or therapeutic injection of an anesthetic/steroid should only be reported when 
imaging confirmation of intra-articular needle positioning with applicable radiological and/or fluoroscopic 
procedures have been performed. 
 
Limitations for Sacroiliac (SI) Joint Injections: 
 
If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for 
immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections 
would not be considered medically necessary. 
 
Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
You can find this information in the  Local Coverage Determination (LCD) Pain Management L33622. 
 
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 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 11 and 12 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 Coverage Indications, Limitations, and/or Medical Necessity 
 
PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the 
following: 
 
1. Inclusion criteria (ALL are required):  
 
    Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) by recent (within 30 days) 
advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) 
    Symptomatic (ONE): 
        Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
equals 8) 
        Non-hospitalized with moderate to severe pain (NRS or VAS equals 5) despite optimal non-surgical 
management (NSM)10* (ONE): 
            Worsening pain 
            Stable to improved pain (but NRS or VAS still equals 5) (with equals 2 of the following): 
                Progression of vertebral body height loss 
                Greater than 25% vertebral body height reduction 
                Kyphotic deformity 
                Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater 
than 17) 
 
* consider including pedicle periosteal infiltration7 
 
c. Continuum of care10 (BOTH): 
 
        All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education for 
subsequent treatment as indicated. 
        All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program.  
2. Exclusion criteria2,5,8-10 (Can have NONE of the following): 
 
a. Absolute contraindication 
 
        Current back pain is not primarily due to the identified acute or subacute VCF(s) 
        Osteomyelitis, discitis or active systemic or surgical site infection 
        Pregnancy 
 
b. Relative contraindication 
 
        Allergy to bone cement or opacification agents 
        Uncorrected coagulopathy 
        Spinal instability 
        Myelopathy from the fracture 
        Neurologic deficit 
        Neural impingement 
        Fracture retropulsion/canal compromise 
        Greater than three vertebral fractures 
 
Vertebral augmentation and KYPHOPLASTY for vertebral compression fractures with intractable spinal pain 
not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma 
involving a vertebral body. You can find this information in Medicare's Local Coverage Determination (LCD): 
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 [summarize the applicable rule/regulation] 
 
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. 
Viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be 
considered medically reasonable and necessary when ALL of the following conditions are met: 
 
   1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily 
living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 
   2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space 
narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
   3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a 
diagnosis other than osteoarthritis of the knee). 
   4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
       - Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, 
physical therapy if indicated); and 
       - If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product 
prescribing information. 
   5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients symptoms and 
intra-articular corticosteroids are not contraindicated. 
 
You can find this rule in the Local Coverage Determination (LCD) for Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427).
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 Guardant360 is covered for patients with non-CNS originated solid tumors who meet the 
criteria of National Coverage Determination (NCD) 90.2 when the following conditions are met: 
- Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did 
not originate from the central nervous system AND 
- Patient has not previously been tested with the Guardant360 test for the same primary cancer. For a patient 
who has been tested previously using Guardant360 for a cancer, that patient may only be tested again when 
the patient has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has 
evidence of new malignant growth, that growth may be considered to be a different primary cancer if it does 
not originate from the same cell line or it is physiologically different enough that it responds differently to 
treatment than the previously tested cancer, AND 
- Patient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. 
progression or new lesions on treatment), AND 
- The patient has decided to seek further cancer treatment with the following conditions: 
      -The patient is a candidate for further treatment with a drug that is either FDA-approved for that patients 
cancer, or has an National Comprehensive Cancer Network (NCCN) 1 or NCCN 2A recommendation for that 
patients cancer, AND 
      - The FDA-approved indication or NCCN recommendation is based upon information about the presence or 
absence of a genetic biomarker tested for in the Guardant360 assay, AND 
-Tissue-based comprehensive genetic profiling (CGP) is infeasible (i.e., quantity not sufficient for tissue-based 
CGP or invasive biopsy is medically contraindicated) OR specifically in non-small-cell lung cancer (NSLC) 
Tissue-based CGP has shown no actionable mutations. 
 
You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Guardant360 (A58192) - 
Effective May 15, 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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when the patient has a personal history of melanoma AND: 
        - Either: 
            Has Stage T1b and above OR 
            Has T1a with documented concern about adequacy of microstaging 
        - Is undergoing workup or being evaluated for treatment, AND 
        - Does not have metastatic disease AND 
        - Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or 
other information is >5% AND 
        - Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended 
use of the test. 
 
You can find this rule in the Local Coverage Determination (LCD) - MolDX: Melanoma Risk Stratification 
Molecular Testing (L37748) - Effective December 6, 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.