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 Covered Indications 
 
A. Facet Joint Interventions: 
 
    Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) Facet Joint 
Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst rupture/aspiration. 
 
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 scale11; 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)4,12; AND 
        3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst)4,7; 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.11 
 
    *Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L34892). 
 
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 phrenic nerve stimulator provides electrical stimulation of the patient's phrenic nerve to 
contract the diaphragm rhythmically and produce breathing in patients who have hypoventilation (a state in 
which an abnormally low amount of air enters the lungs).  The device has been used successfully to treat 
hypoventilation caused by a variety of conditions, including respiratory paralysis resulting from lesions of the 
brain stem and cervical spinal cord and chronic pulmonary disease with ventilatory insufficiency. The phrenic 
nerve stimulator is intended to be an alternative to management of patients with respiratory insufficiency who 
are dependent upon the usual therapy of intermittent or permanent use of a mechanical ventilator as well as 
maintenance of a permanent tracheotomy stoma. 
 
However, an implanted phrenic nerve stimulator can be effective only if the patient has an intact phrenic nerve 
and diaphragm. Moreover, nerve injury may occur during the surgical procedure and if sufficient injury is 
incurred, the device will not prove useful to the patient. Consequently, it is possible for such a device to be 
indicated for a patient but, due to injury sustained during implant, fail to assist the patient, resulting in a return 
to the use of mechanical ventilation. 
 
The implantation of a phrenic nerve stimulator is covered for selected patients with partial or complete 
respiratory insufficiency. You can find this information in the Centers for Medicare and Medicaid Services 
(CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) 
Manual, Section 160.19. 
 
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 
cleaning, dental x-rays, fluoride treatment, and oral exam. The Plan contract also says that the Plan offers 
comprehensive dental benefits. You can find this information on page 47 of the Plans 2022 Evidence of 
Coverage (EOC). 
 
The Plan contract includes a list of covered supplemental dental services. The contract specifically says that 
any procedure not listed is not covered. Collection and application of autologous blood concentrate product 
(D7921) is not included on this list and is not a covered supplemental benefit. You can find this information in 
the Plan's 2022 dental benefit document.
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of 
the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(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 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 $40 copayment for podiatry services. You can find this information in 
Chapter 4 on page 94 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 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 the submission of claims using individual gene CPT codes, when either 5-50 or >50 gene panels 
are ordered, is considered incorrect coding. Correct coding requires that when a panel code is ordered, it should 
be billed, rather than the individual gene codes. CPT code 81445 or 81450 should be billed when 5 to 50 genes 
are ordered. CPT code 81455 should be billed when 51 or greater genes are ordered for molecular biomarkers. 
When a panel with greater than one or less than five genes is ordered, use the corresponding existing panel 
CPT code or CPT code 81479 if none exists.  
 
Coding Information: 
 
Coding guidance in this article is categorized into four, distinct CPT/HCPCS sections:  
 
Group 3 Paragraph 
 
Tier 1 Non-covered Codes 
 
Genetic testing procedures submitted under the following CPT codes are unlikely to impact therapeutic 
decision-making in the clinical management of the patient and will be denied automatically as not medically 
necessary. You can find this rule in the Local Coverage Article Billing and Coding: Molecular Pathology 
Procedures A56199. 
 
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 weight management programs may be offered as a supplemental benefit designed to promote 
healthy behaviors that help an individual to lose weight and keep it off, but the program may not offer meals as 
part of the benefit. As with all supplemental benefits, Weight Management Programs must be health driven and 
aim to improve health outcomes. For the Centers for Medicare & Medicaid Services (CMS) to consider a 
Weight Management Program sufficiently health related, the benefit includes: 
  A plan to keep the weight off over the long run: 
  Guidance on how to develop healthier eating and physical activity habits; and 
  Ongoing feedback, monitoring, and support. 
 
The weight management program should provide structured lessons on a weekly basis that are tailored to the 
beneficiaries personal goals. The program should support self-monitoring of eating and physical activity as 
well as offer regular feedback from a counselor on goals, progress, and results. The program may be offered 
online (fully or partly), but must also be entirely available to enrollees without access to online capabilities. 
 
You can find this information in the 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 the Plan will reimburse members up to a maximum of $150 per calendar year towards program fees for 
weight loss programs. The Plan contract also says to obtain this reimbursement, please submit a Weight 
Management reimbursement form along with proof of payment and any additional information outlined on the 
form. You can find this information on pages 78 and 79 of the Plan's 2021 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 the following indications are covered nationally unless otherwise indicated: 
 
    1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
    2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
    3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed as 
a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the 
time the service is performed or immediately thereafter. 
    4. Home EKG services with documentation of medical necessity. 
    5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to 
the physicians service in interpreting the results of such transmissions, including charges for rental of the 
equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME 
separately. Covered uses are to: 
        a. Detect, characterize, and document symptomatic transient arrhythmias; 
       b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
        c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only 
if 24-hour coverage is provided). You can find this information in Medicare's National Coverage Determination 
(NCD): Electrocardiographic Services (20.15). 
 
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 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 $40 copayment for a specialists visit. You can find this information on 
page 88 of the Plan's 2021 Evidence of Coverage (EOC) and page 111 of the Plans 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 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 $285 copayment for ambulance services. You can find this information 
on page(s) 61 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). 
 
The rules say that contract suppliers are not required to furnish a specific brand name item or mode of delivery 
to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. 
A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) 
may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an item if he or 
she determines that the particular brand or mode of delivery is necessary to avoid an adverse medical outcome 
for the beneficiary. The physician or treating practitioner must document in the beneficiary's medical record the 
reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. 
This documentation should include the following: 
 The product's brand name or mode of delivery; 
 The features that this product or mode of delivery has versus other brand name products or 
modes of delivery; and 
 An explanation of how these features are necessary to avoid an adverse medical outcome. 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 36 - Contract Supplier Responsibilities, 
Section 30.4 - Prescription for Particular Brand, Item, or Mode of Delivery. 
 
The payment amount for a given service or item, whether rented or purchased, must be consistent with what is 
reasonable and medically necessary to serve the intended purpose. Additional expenses for "deluxe" features, 
or items that are rented or purchased for aesthetic reasons or added convenience, do not meet the 
reasonableness test.  
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies, Section 90 - Payment for Additional Expenses for Deluxe Features. 
 
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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
  
   
    The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; 
    With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient; 
    Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
    All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be available; and 
    Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
Medicare Administrative Contractors may find it helpful to work with Quality Improvement Organizations to 
obtain the information needed to apply these conditions to claims. You can find this information in Medicare's 
National Coverage Determination (NCD): Electrical Nerve Stimulators (160.7). 
 
The rules say SCS therapy should be considered as a late option after more conservative attempts such as 
medications, physical therapy, psychological therapy or other modalities have been tried. 
 
Patients must have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation). Documentation of 
the history and careful screening must be available in the patient chart if requested. Patients being selected for a 
trial 
 
    Must not have active substance abuse issues. 
    Must undergo proper patient education, discussion, and disclosure including an extensive discussion of the 
risks and benefits of this therapy. 
    Must undergo appropriate psychological screening 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Spinal Cord Stimulators for 
Chronic Pain (L36204). 
 
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 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The plan 
provides a supplemental benefit for meals delivery following discharge from a hospital due to congestive heart 
failure, up to two meals per day in a consecutive four-week period, once per calendar year. This information is 
found on page 71 of the 2022 Evidence of Coverage.