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 state that epidural steroid injections (ESI) will be considered medically reasonable and necessary 
when the following requirements are met: 
A. History, physical examination, and concordant radiological image-based diagnostic testing that supports 
one of the following: 
a. Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis
 
OR 
b. Post-laminectomy syndrome, OR 
c. Acute herpes zoster associated pain. 
AND 
B. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality 
of life or function. An objective pain scale or functional assessment must be performed at baseline 
(prior to interventions). The same scale* must be used at each follow-up for assessment of response. 
AND 
C. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute 
herpes zoster refractory to conservative management where a four (4) week wait is not required. 
The rules say that the repeat ESI when the first injection directly and significantly provided improvement of the 
condition being treated may be considered medically reasonable and necessary when the medical record 
documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using SAME scale for at least three months. If a patient fails to respond well to the initial ESI, a repeat 
ESI after 14 days can be performed using a different approach, level and/or medication, if appropriate, with the 
rationale and medical necessity for the second ESI documented in the medical record. 
 
You can find these rules in the Local Coverage Determination (LCD) for Epidural Steroid Injections for Pain 
Management, L36920. 
 
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 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 health 
plan contract says that twenty-four (24) one-way trips to plan-approved locations every year, provided by the 
network transportation provider. You can find this information in Chapter 4 on page 89 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 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 Physician Fee Schedule Status Indicator P means that there are no RVUs and no payment 
amounts for these services. No separate payment is made for them under the fee schedule. 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, 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 facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL of the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional 
deficit measured on pain or disability scale; AND 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management (as tolerated); AND 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused 
by facet joint synovial cyst); AND 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or 
significant deformity. 
 
Diagnostic Facet Joint Injection Procedures (IA or MBB): 
 
The primary indication of a diagnostic facet joint procedure is to diagnose whether the patient has facet 
syndrome.
 
Intraarticular (IA) facet block(s) are considered medically reasonable and necessary as a diagnostic 
test only if MBB cannot be performed due to specific documented anatomic restrictions or there is an 
indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly documented 
in the medical record and made available upon request. 
Diagnostic procedures should be performed with the intent that if successful, a RFA procedure would be 
considered the primary treatment goal at the diagnosed level(s). 
A second diagnostic facet procedure is considered medically reasonable and necessary to confirm validity of 
the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure. 
1. An initial diagnostic facet joint procedure will be considered medically reasonable and 
necessary when the patient meets the criteria outlined under the indications for facet joint 
interventions. 2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet BOTH of the following criteria:  
 The patient meets the criteria for the first diagnostic procedure; AND 
 After the first diagnostic facet joint procedure, there must be a consistent positive 
response of at least 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). 
You can find this in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L33930). 
 
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 pages 3-4 of the Plans 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 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. 
 
The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which 
the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 
Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood).  A physician's order 
and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity 
of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific 
event cannot be identified.  Replacement of equipment due to irreparable wear takes into consideration the 
reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual, 
Chapter 15, Section 100.2. 
 
The rules say that the reasonable useful lifetime of durable medical equipment is determined through program 
instructions. In the absence of program instructions, A/B MACs 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 Medicare Benefit Policy 
Manual, Chapter 15, Section 100.2. 
 
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 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. 
 
The rules say that a Medicare Plan is financially responsible for emergency services regardless of whether the 
services are obtained within or outside the Plan. Emergency services are covered whether there is prior 
authorization for the services. An emergency is defined as when a person would believe that without immediate 
medical attention there would be serious jeopardy to his or her health. You can find this rule at 42 CFR Section 
422.113(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 testing for the Fanconi anemia, complementation group C (FANCC) is not a Medicare 
benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of 
tests that include the FANCC gene. 
 
You can find these rules in the Local Coverage Article Billing and Coding: MolDX: FANCC Genetic Testing, 
A53628. 
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 LAAC is covered if there is a formal shared decision-making interaction with an 
independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in 
patients with non-valvular atrial fibrillation (NVAF) prior to LAAC. Additionally, the shared decision-making 
interaction must be documented in the medical record. You can find this information in the Centers for 
Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-3 National Coverage 
Determination (NCD) 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 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 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, 30.2.2. 
 
The rules say that Home Health Agencies (HHAs) must report where home health services were provided. The 
following codes are used for this reporting: Q5001: Hospice or home health care provided in patient's 
home/residence; Q5002: Hospice or home health care provided in assisted living facility; Q5009: Hospice or 
home health care provided in place not otherwise specified. The location where services were provided must 
always be reported along with the first visit reported on the claim. In addition to reporting a visit line using the 
G codes as described above, HHAs must report an additional line item with the same revenue code and date of 
service, reporting one of the three Q codes (Q5001, Q5002, and Q5009), one unit and a nominal covered 
charge (e.g., a penny). If the location where services were provided changes during the period of care, the new 
location should be reported with an additional line corresponding to the first visit provided in the new location. 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, 40.2. 
 
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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 certain dental services as a supplemental (extra) benefit. This benefit includes a 
complete lower denture once every 5 Plan years. You can find this information on page 4-64 of the Plans 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 a seat lift mechanism is covered if all of the following criteria are met: 
1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 
2. The seat lift mechanism must be a part of the treating practitioners course of treatment and be prescribed to 
effect improvement, or arrest or retard deterioration in the beneficiary's condition. 
3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their 
home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a 
low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of 
ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.) 
4. Once standing, the beneficiary must have the ability to ambulate. 
You can find this information in the Local Coverage Determination (LCD): Seat Lift Mechanisms (L33801). 
 
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 each Medicare-covered medical supply. You can 
find this information in Chapter 4 on page 4-41 of the Plan's 2021 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $30 copayment for Medicare-covered non-radiological 
diagnostic services. You can find this information in Chapter 4 on page 4-43 of the Plans 2021 Evidence of 
Coverage (EOC). 
 
The Plan contract say that enrollees must pay a $155 copayment for Medicare-covered radiological diagnostic 
services, not including X-rays, preformed in a physicians office or at a free-standing facility. You can find this 
information in Chapter 4 on page 4-44 to 4-45 of the Plans 2021 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 treatment for lower urinary tract symptoms attributable to benign prostatic hyperplasia 
(LUTS/BPH) will be considered reasonable and necessary when performed ONCE in patients with the 
following: 
1. Indications including ALL of the following: 
a. Age less than or equal to 80 
b. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
c. Persistent moderate to severe symptoms despite maximal medical management including ALL 
of the following: 
i. International Prostate Symptom Score (IPSS) greater than or equal to 12 
ii. Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume 
greater than 125 cc) 
iii. Failure, contraindication or intolerance to at least three months of conventional medical 
therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) for Fluid Jet System Treatment for 
LUTS/BPH, L38367. 
 
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 botulinum toxins for treatment of anal spasm, irritable colon, biliary dyskinesia, or any 
treatment of spastic conditions not listed as covered in this policy are considered to be cosmetic, 
investigational, or not safe and effective. You can find these rules in Local Coverage Determination (LCD) 
Botulinum Toxin Types A and B (L35172). 
 
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.