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 testing which is intended to diagnose and characterize the neurocognitive effects of medical 
disorders that impinge directly or indirectly on the brain. Examples of problems that might lead to 
neuropsychological testing are: 
 
- Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head 
injury, anoxic injuries, AIDS dementia) 
- Differential diagnosis between psychogenic and neurogenic syndromes 
- Delineation of the neurocognitive effects of central nervous system disorders 
- Neurocognitive monitoring of recovery or progression of central nervous system disorders; or 
- Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies 
among individuals with neuropsychiatric disorders. 
 
Typically, psychological testing will require from four (4) to six (6) hours to perform, including administration, 
scoring and interpretation. Supporting documentation in the medical record must be present to justify greater 
than 8 hours per patient per evaluation. If the testing is done over several days, the testing time should be 
combined and reported all on the last date of service. If the testing time exceeds eight (8) hours, medical 
necessity for extended time should be documented. Medical records may be requested. 
 
You can find this information in the Local Coverage Determination (LCD): Psychiatry and Psychology 
Services (L33632). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles, and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a 20% coinsurance for all other Medicare-covered Part B drugs besides 
Medicare-covered Part B allergy antigens. You can find this information on page 4-28 of the Plan's 2022 
Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a 20% coinsurance for each Medicare-covered medical supply. 
You can find this information on page 4-32 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $20 copayment for Medicare-covered non-radiological 
diagnostic services, which includes treadmill stress tests. You can find this information on page 4-33 of the 
Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $75 copayment for Medicare-covered radiological 
diagnostic services, which includes nuclear studies, performed in a physicians office or at a free-standing 
facility (such as a radiology center or medical clinic). You can find this information on page 4-34 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 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 $10 copayment for outpatient diagnostic tests, including x-rays. You can 
find this information on page(s) 69 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 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). 
 
Payment may be made for the replacement of a prosthetic device that is an artificial limb, or replacement part 
of a device if the ordering physician determines that the replacement device or part is necessary because of any 
of the following: 
1. A change in the physiological condition of the patient; 
2. An irreparable change in the condition of the device, or in a part of the device; or 
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual Chapter 15, Section 120. 
 
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 $75 copayment for each in-network Medicarecovered diagnostic 
procedure and test performed by a provider other than your primary care physician. You can find this 
information on page(s) 74 and 75 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 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 $275 copayment for in-network outpatient surgery provided at an 
ambulatory surgical center. You can find this information on page(s) 104 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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance 
and self-esteem. 
 
Cosmetic surgery performed purely for the purpose of enhancing one's appearance is not eligible for coverage. 
 
However, surgery to correct congenital defects, developmental abnormalities, trauma, infections, tumors or 
disease may be covered, because the surgery is considered reconstructive in nature. 
 
Cosmetic surgery performed to treat psychiatric or emotional problems is generally not covered. 
 
Corrective facial surgery will be considered cosmetic, rather than reconstructive, when there is no functional 
impairment present. However, some congenital, acquired, traumatic or developmental anomalies may not result 
in functional impairment, but are so severely disfiguring as to merit consideration for corrective surgery, e.g., 
craniofacial anomalies associated with Treacher Collins syndrome may be considered on an individual basis. 
 
If a non-covered cosmetic surgery is performed in the same operative period as a covered surgical procedure, 
benefits will be provided for the covered surgical procedure only. Benefits are provided for complications arising from cosmetic surgery, as long as infection, hemorrhage or 
other serious documented medical complication occurs, and the beneficiary has been officially discharged from 
the facility. 
 
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L33428). 
 
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 LAAC devices are covered when the device has received Food and Drug Administration 
(FDA) Premarket Approval (PMA) for that devices FDA-approved indication and meet all of the conditions 
specified below: 
The patient must have: 
- A CHADS2 score at least () 2 (Congestive heart failure, Hypertension, Age > 75, Diabetes, 
Stroke/transient ischemia attack/thromboembolism) or CHA2DS2-VASc score  3 (Congestive heart 
failure, Hypertension, Age  65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular 
disease, Sex category) 
- A formal shared decision-making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. 
Additionally, the shared decision-making interaction must be documented in the medical record. 
- A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following 
the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral 
anticoagulants. The patient (preoperatively and postoperatively) is under the care of a cohesive, 
multidisciplinary team (MDT) of medical professionals. The procedure must be furnished in a hospital 
with an established structural heart disease (SHD) and/or electrophysiology (EP) program. 
You can find this information in National Coverage Determination (NCD): Percutaneous Left Atrial 
Appendage Closure (LAAC) (20.34). 
 
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 contractors should discontinue processing the transitional drug add-on payment 
adjustment (TDAPA) for J0604 and J0606 when billed with modifier AX on Type of Bill 72X for from dates 
on or after January 1, 2021. You can find this rule in the Centers for Medicare and Medicaid System (CMS) 
Manual System, Publication 100-02, Medicare Benefit Policy Manual, Transmittal 10568, Change Request 
12011. 
 
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 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 must be retained in the treating 
practitioner's or prosthetist's files. You can find this information in the 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 say that cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
Services that are considered cosmetic for the treatment of gender dysphoria are not covered. 
This list is not all-inclusive: 
 Liposuction: removal of fat 
 Rhinoplasty: reshaping of nose 
 Rhytidectomy: face lift 
 Blepharoplasty: removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat 
 Hair removal/ hair transplantation 
 Facial feminizing (e.g., facial bone reduction) 
 Chin augmentation: reshaping or enhancing the size of the chin 
 Collagen injections 
 Lip reduction/enhancement: decreasing/enlarging lip size 
 Cricothyroid approximation: voice modification that raises the vocal pitch by simulating contractions of 
the cricothyroid muscle with sutures 
 Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage 
 Laryngoplasty: reshaping of laryngeal framework (voice modification surgery) 
 Mastopexy: breast lift 
 
Local Coverage Determination (LCD): Billing and Coding: Gender Reassignment Services for Gender 
Dysphoria (A53793). 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving distance. You can 
find this information on pages 121-122 of the Plans 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 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 while electric nerve stimulation has been employed to control chronic intractable pain for 
some time, its use in the treatment of motor function disorders, such as multiple sclerosis, is a recent 
innovation, and the medical effectiveness of such therapy has not been verified by scientifically controlled 
studies. You can find this rule in National Coverage Determination (NCD) Treatment of Motor Function 
Disorders with Electric Nerve Stimulation 160.2. 
 
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 for all services (with two (2) exceptions), the place of services (POS) code to be used by the 
physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-
face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which 
case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face 
service takes place. You can find this information in the MLN Matters article number MM7631, Revised and 
Clarified Place of Service (POS) Coding Instructions. 
 
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. 
 
A pneumatic compression device (PCD) coded as E0652 is covered for the treatment of lymphedema extending 
onto the chest, trunk and/or abdomen when all of the following are met: 
1. The beneficiary has lymphedema of an extremity. 
2. The coverage criteria for an E0650 or E0651 PCD are met. 
3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed 
to improve with a four-week trial. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 
is required. The four-week trial of conservative therapy must include all of the following: 
 
 At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after 
careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided 
 Compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression 
 Regular exercise 
 Elevation where appropriate 
 Manual lymphatic drainage (where available) and self-manual lymphatic drainage (MLD) for at least 30 
minutes per day 
 Evaluation of diet and implementation of any necessary change 
 Medications as appropriate (e.g. diuretics and/or other treatment of congestive failure, etc.) 
 Correction (where possible) of anemia and/or hypoproteinemia 
 
You can find this information at Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829).  
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.