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 this Medicare contractor will provide limited coverage for molecular Deoxyribonucleic acid 
(DNA)/Ribonucleic acid (RNA) assays that aid in the diagnosis or exclusion of melanoma from a biopsy when 
ALL of the following clinical conditions are met: 
 The test is ordered by a board-certified or board-eligible dermatopathologist  
 The specimen is a primary (non-metastatic, non-re-excision specimen) cutaneous melanocytic neoplasm 
for which the diagnosis is equivocal/uncertain (i.e., clear distinction between benign or malignant 
cannot be achieved using clinical and/or histopathological features alone) despite the performance of 
standard-of-care test procedures and relevant ancillary tests (i.e., immunohistochemical stains)  
 The specimen includes an area representative of the lesion or portion of the lesion that is suspicious for 
malignancy 
 The patient may be subjected to additional intervention, such as re-excision and/or sentinel lymph node 
biopsy, as a result of the diagnostic uncertainty 
 The patient has not been tested with the same or similar assay for the same clinical lesion 
 The test is validated for use in the intended-use population and is performed according to its stated 
intended-use  
 The test demonstrates Analytical and Clinical Validity (AV and CV) and Clinical Utility (CU) and 
undergoes a technical assessment (TA) by MolDX to demonstrate compliance of the service with this 
policy 
You can find this rule in Local Coverage Determination (LCD) MolDX: Molecular Assays for the Diagnosis of 
Cutaneous Melanoma L39373. 
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 percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required):  
 
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) 
(T1  L5) by recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance 
imaging (MRI) or bone-scan/single photon emission computed tomography (SPECT)/computed 
tomography (CT) uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score of 8 or more) 
ii. Non-hospitalized with moderate-to-severe pain (NRS or VAS of 5 or more) despite 
optimal non-surgical management (NSM)1 (ONE): 
1. Worsening pain 
2. Stable-to-improved pain (but NRS or VAS still 5 or more) (with 2 or more of 
the following): 
A. Progression of vertebral body height loss 
B. More than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris 
Disability Questionnaire (RDQ) more than 17) 
c. Continuum of care (BOTH): 
i. All patients presenting with VCF should be referred for evaluation of bone mineral density 
(BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
 2. Exclusion criteria (Can have NONE of the following): 
 a. Absolute contraindication: 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy  
 b. Relative contraindication: 
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than 3 vertebral fractures 
 
You can find these rules in 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. 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 
 
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management with and without methods of immobility. 
 
-Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are met: 
 -Acute (<6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 L5) and 
 -The beneficiary is symptomatic and is hospitalized with severe pain or is non-hospitalized with 
moderate to severe pain despite optimal non-surgical management with one of the following: 
  -Worsening Pain or 
  -Stable to improved pain when 2 or more of the following are present: 
   -Progression of vertebral body height loss 
   -> 25% vertebral body height reduction 
   -Kyphotic deformity 
   -Severe impact of VCF on daily functioning  
 
1. Exclusion criteria  
 -Absolute contraindication 
  -Current back pain is not primarily due to the identified acute or subacute VCF(s). 
  -Osteomyelitis, discitis or active systemic infection 
  -Pregnancy 
  -Active surgical site infection 
 -Relative contraindication 
  -Greater than three vertebral fractures per procedure 
  -Allergy to bone cement or opacification agents 
  -Uncorrected coagulopathy 
  -Spinal instability 
  -Myelopathy from the fracture   -Neurologic deficit 
  -Neural impingement 
  -Fracture retropulsion/canal compromise 
 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 $90 copayment for emergency room visits. You can find this 
information on pages 60 to 61 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 say that members receive up to 60 hours per year of in-home support services including light house 
help, companionship services, grocery shopping, technology lessons, and social transportation. 
 
This benefit does not include services involving Activities of Daily Living (ADLs) and Instrumental Activities 
of Daily Living (IADLs) within the home such as personal assistance with:  
-Bathing  
-Dressing and personal hygiene 
-Grooming  
-Mouth care  
-Toileting  
-Transferring bed/chair 
Once the member exhausts their 60 hours in the plan year, they will no longer be eligible to receive this benefit. 
You can find these rules on page 71 of the Plan's 2023 EOC. 
 
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 there are some patients who require supplementation of their daily protein and caloric intake. 
These nutritional supplements are often given as a medicine between meals to boost protein-caloric intake or 
the mainstay of a daily nutritional plan. Medicare does not pay for nutritional supplements. You can find this 
information in the Local Coverage Determination (LCD): Enteral Nutrition (L38955) and the related Local 
Coverage Article: Enteral Nutrition  Policy Article (A58833). 
 
Enteral nutrition is covered for a beneficiary who requires feedings via an enteral access device to provide 
sufficient nutrients to maintain weight and strength commensurate with the beneficiary's overall health status 
and has a permanent: 
A. full or partial non-function or disease of the structures that normally permit food to reach the small bowel; 
OR, 
B. disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small bowel. 
Adequate nutrition must not be possible by dietary adjustment and/or oral supplement 
You can find this information in the Local Coverage Determination (LCD) Enteral Nutrition L38955. 
 
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 respite care is short-term inpatient care provided to the individual only when necessary to 
relieve the family members or other persons caring for the individual at home. Respite care may only be 
provided in a Medicare participating hospital or hospice inpatient facility, or a Medicare or Medicaid 
participating nursing facility. Respite care may be provided only on an occasional basis and may not be 
reimbursed for more than 5 consecutive days at a time. Respite care provided for more than 5 consecutive days 
at a time must be billed as routine home care for day 6 and beyond, and the patient may be liable for room and 
board charges for day 6 and beyond. You can find this information in the Medicare Benefit Policy Manual, 
Chapter 9- Coverage of Hospice Services Under Hospital Insurance, Section 40.2.2. 
 
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 also says that short-term respite care is only covered under the hospice care benefit. You can find this 
information on pages 66-67 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 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 $30 copayment for in-network outpatient mental health care. You can 
find this information on page(s) 102 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.   
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. MUEs for codes with an MAI of 2 are absolute date of service edits. These are per day edits 
based on policy. Codes with an MAI of 2 have been rigorously reviewed and vetted within CMS and obtain 
this MAI designation because units of service on the same date of service (DOS) in excess of the MUE value 
would be considered impossible because it was contrary to statute, regulation, or subregulatory guidance. You 
can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter I(V).  
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. You can find this rule in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 20.9. 
 The rules say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that providers/suppliers must report units of service correctly. Each HCPCS/CPT code has a 
defined unit of service for reporting purposes. A provider/supplier shall not report UOS for a HCPCS/CPT 
code using a criterion that differs from the codes defined unit of service. For example, some therapy codes are 
reported in fifteen-minute increments (e.g., CPT codes 97110-97124). Others are reported per session (e.g., 
CPT codes 92507, 92508). A provider/supplier shall not report a per session code using fifteen-minute 
increments. CPT code 92507 or 92508 should be reported with one unit of service on a single date of service. 
You can find this rule in the National Correct Coding Initiative Policy Manual for Medicare Services; Chapter 
1, General Correct Coding Policies. 
 
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 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 state that replacement of a prosthesis or prosthetic component is covered if the treating physician 
orders a replacement device or part because of any of the following: 
1. A change in the physiological condition of the beneficiary; or 
2. Irreparable wear of the device or a part of the device; or 
3. The condition of the device, or part of the device, requires repairs and the cost of such repairs 
would be more than 60% of the cost of a replacement device, or of the part being replaced. 
 
Replacement of a prosthesis or prosthetic components required because of loss or irreparable damage may be 
reimbursed without a physician's order when it is determined that the prosthesis as originally ordered still fills 
the beneficiary's medical needs. You can find this rule in Medicare Benefit Policy Manual Chapter 15 - 
Covered Medical and Other Health Services, Section 120 D. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
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 abdominal aortic aneurysm screenings are limited to a one-time screening ultrasound for people at risk. 
You can find this information on page 44 of the Plans 2023 Evidence of Coverage.