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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL 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* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
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. 
 
*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). 
 
The thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial 
branch) nerves are considered medically reasonable and necessary for patients who meet ALL the following 
criteria for Initial thermal RFA: 
 
a. After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with 
each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of 
relief being consistent with the agent used) AND 
b. Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and 
necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) 
months or at least 50% consistent improvement in the ability to perform previously painful movements and 
ADLs as compared to baseline measurement using the same scale; 
 
For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 
months. You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions 
for Pain Management (L35936). 
 
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 use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care 
(MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically 
reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. 
In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific 
patient. You can find this information in Local Coverage Determination (LCD): Epidural Steroid Injections for 
Pain Management (L39036). 
 
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 Plan 
contract states that only Medicare-covered dental services are covered. You can find this information on page 
57 of the Plan's 2020 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 type I polysomnography (PSG) is covered when used to aid the diagnosis of obstructive 
sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed 
attended in a sleep lab facility. 
 
You can find this information in the National Coverage Determination (NCD) for SLEEP TESTING FOR 
OBSTRUCTIVE SLEEP APNEA (OSA) (240.4.1). 
 
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 viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when all of the following conditions are 
met: 
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of 
daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee 
stiffness. 
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint 
space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due 
to a diagnosis other than osteoarthritis of the knee). 
4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
 Nonpharmacologic therapy (such as but not limited to home exercise program, education, 
weight loss, physical therapy if indicated); and 
 If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan 
product prescribing information. 
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients 
symptoms and intra-articular corticosteroids are not contraindicated. 
 
You can find this information in Local Coverage Determination (LCD): Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427). 
 
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 say that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial 
branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) 
medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% 
sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). You 
can find this rule in 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 custom fabricated mandibular advancement oral appliance (E0486) used to treat 
obstructive sleep apnea (OSA) is covered if criteria A - D are met. 
 
    A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-related 
Policy Article for applicable diagnoses. 
    B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3): 
           1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 
15 events per hour with a minimum of 30 events; or, 
           2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a 
minimum of 10 events and documentation of: 
                a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
                b. Hypertension, ischemic heart disease, or history of stroke; or, 
           3. If the AHI> 30 or the RDI> 30 and meets either of the following(a or b): 
                a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
                b. The treating practitioner determines that the use of a PAP device is contraindicated. 
    C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who performed the 
clinical evaluation in criterion A.) 
    D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. 
 
Refer to the NONMEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the Policy 
Article for information about coverage for appliances that achieve their effect through positioning of the tongue 
(A9270). 
 
A prefabricated oral appliance (E0485) will be denied as not reasonable and necessary. There is insufficient 
evidence to show that these items are effective therapy for OSA. You can find this rule in the Local Coverage 
Determination (LCD) Oral Appliances for Obstructive Sleep Apnea L33611. 
 
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 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 if after the first 
diagnostic facet joint procedure, there is 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 these rules in 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. 
 
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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules also say that Rural Health Clinics (RHCs) paid under the All-Inclusive Rate (AIR) are required to file 
a cost report annually in order to determine their payment rate. If a RHC is in its initial reporting period, the 
Medicare Administrative Contractor (MAC) calculates an interim rate based on a percentage of the per-visit 
limit, which is then adjusted when the cost report is filed. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 9, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 subcutaneous insulin is administered using ambulatory infusion pump E0784. Claims for 
usage of infusion pumps other than E0784 will be denied as not reasonable and necessary. 
 
The rules say that this item is covered under certain conditions. The member must meet criterion A or B AND 
C or D: 
A. Has to meet the testing requirements that shows that your body is not making enough insulin (fasting C- 
Peptide); 
o C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory's 
measurement method; or 
o For poor kidney function (renal insufficiency) and abnormal lab tests (a creatinine clearance less than or 
equal to 50 ml/minute, a fasting C-peptide level is less than or equal to 200 per cent of the lower limit of 
normal of 
the laboratorys measurement method); and 
o A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 mg/dl 
B. Has a test that shows that you have Type I Diabetes (Beta cell autoantibody positive) 
C. Has been using insulin at least three times per day and making frequent changes to your insulin dose for 
at least 6 months prior to the start of the insulin pump; and 
 Has to be self-testing blood sugar levels an average of at least 4 times per day during the 2 months 
before starting insulin pump therapy; and 
 Meets one of the following criteria (1-5): 
1. Average blood sugar over the past 3 months (HbA1C) greater than 7.0% 
2. History of recurring low blood sugars (hypoglycemia) 
3. Wide range in blood sugar levels before mealtime 
4. Fasting blood sugars frequently go above 200 mg per dl 
5. History of having severe changes in your blood sugar levels (severe glycemic excursions) 
D. Has been on an external insulin infusion pump and there is a record of blood sugars being taken at least 
4 times per day. 
 
You can find this rule in the Local Coverage Determination (LCD) External Infusion Pumps L33794. 
 
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 page 12 of the 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 Pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
    1. The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
 
    2. The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-
reviewed process and determined to demonstrate actionability in clinical decision making. 
 
Genetic testing where either analytical validity, clinical validity, or clinical utility has not been established is 
considered not medically reasonable and necessary.  
 
You can find this rule in the Local Coverage Determination (LCD): Pharmacogenomics Testing (L39073). 
 
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 page 6 and 7 of the 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 state that Proton Beam radiotherapy is coverable when medically necessary for certain 
conditions.  The patient's medical record must demonstrate why proton beam radiotherapy is considered the 
treatment of choice for the individual patient.  In addition, the following criteria must be met: 
 
1. the dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with 
other indicated methods; or  
 
2. there is a reason to believe that doses generally thought to be above the level otherwise attainable with other 
methods might improve control rates; or 
 
3.In circumstances when the higher levels of precision associated with proton beam therapy as compared to 
other radiation methods are necessary, i.e., clinically relevant; AND 
 
4. for the treatment of primary leasions, the intent of treatment must be curative; OR 
5. for the treatment of metastatic lesions, there must be an expectation of long-term benefit that could not have 
been attained with conventional therapy or the expectation of a complete eradication of the metastatic lesion 
that could not have been accomplished by other means. 
 
In addition, the record must address the lower risk to normal tissue, the lower risk of disease recurrence, and 
the advantages of the treatment over intensity-modulated radiation therapy (IMRT) or 3-dimensional conformal 
Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained.  
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L33937 
entitled Proton Beam Radiotherapy. 
 
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.