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 the indications for myocardial perfusion imaging include: 
 
1. Acute myocardial infarction (AMI) - MPI is not typically performed during the acute period of myocardial 
infarction (MI), if the diagnosis is established by other means. In selected patients, imaging is appropriate in 
the assessment of: 
Disease severity 
Risk assessment and/or prognosis 
Efficacy of acute reperfusion therapy 
Evidence of myocardial salvage 
Suspected infarction when the combination of history and other tests is not diagnostic. 
2. Unstable angina - MPI may be useful as an adjunct to other tests in the diagnosis or treatment of unstable 
angina only when the combination of history and other tests is not diagnostic. In selected patients, imaging is 
appropriate for: 
Identification of ischemia in the distribution of a known lesion or in remote areas 
Identification of the severity/extent of disease in patients with medically unstable angina or 
ongoing ischemia 
Measurement of left ventricular function (LVF). 
  3. Chronic ischemic heart disease - The use of MPI is well established in the diagnosis and management of 
CAD and is covered in these situations: 
Diagnosis of CAD, especially in patients with atypical chest pain 
Evaluation of abnormal or suspected false positive stress ECG 
Evaluation of other symptoms suspicious for the diagnosis of CAD such as syncope and 
ventricular arrhythmia 
Assessment of myocardial viability after revascularization or medical management 
Planning percutaneous transluminal coronary angioplasty (PTCA) to identify lesions causing 
ischemia, if unknown 
Evaluation of suspected or known CAD prior to high risk surgical procedure 
Identification of the presence, location, extent, and severity of myocardial ischemia 
Assessment of drug therapy 
Assessment of symptoms suggesting restenosis following PTCA 
Assessment of symptoms suggesting ischemia following Coronary Artery Bypass Graft (CABG) 
Follow up of symptomatic ischemic heart disease 
4. Congenital heart disease (CHD) - Echo is the method of choice for evaluating patients with known or 
suspected CHD. Selected patients may benefit from MPI when assessing for: 
Diagnosis of anomalies of the coronary circulation 
Kawasakis disease 
5. Post-transplant cardiac disease 
Assessment of coronary arteriopathy 
Evaluation for ventricular dysfunction with post-transplant rejection 
You can find this information in the Local Coverage Determination (LCD) L33457: Cardiac Radionuclide 
Imaging. 
 
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 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 say that the clinical record must clearly show the use of or intent to prescribe a drug that has known 
drug-gene interactions that require a PGx test to be ordered to define the safe use of that drug in that patient. 
You can find this information in the Local Coverage Article (LCA): Pharmacogenomics Testing (A58801). 
 
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 the following indications for BRCA1 and BRCA2 testing are covered by Medicare: 
 Individual with breast, ovarian
1
, pancreatic, or prostate cancer from a family with a known deleterious 
BRCA1 or BRCA2 gene mutation 
 Individual with a personal history of ovarian cancer 
 Individual with a breast cancer diagnosis 
 Personal history of pancreatic cancer at any age 
 Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease) 
 BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor type in the absence of 
germline mutation analysis 
BRCA1/BRCA2 genetic testing is not reasonable and necessary, thus it is non-covered, for the following 
indications: 
 Genetic screening in the general population. Such testing is considered screening and is excluded by 
Medicare statute.  
 Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, 
pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute.  
 
You can find this rule in the Local Coverage Determination for Molecular Diagnostics Service Program 
(MolDX): BRCA1 and BRCA2 Genetic Testing, L36163. 
 
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 cardiovascular stress testing with or without cardiac imaging if the results will not affect 
patient management decisions is not covered. You can find this rule at Local Coverage Determination (LCD) 
L38396: Cardiology Non-emergent Outpatient Stress Testing (eff. 4/25/21). 
 
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 group I criteria include any of the following: 
 
    1. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest 
(awake), or 
    2. An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 
5 minutes taken during sleep for a beneficiary who demonstrates an arterial PO2 at or above 56 mm Hg or an 
arterial oxygen saturation at or above 89 percent while awake, or 
    3. A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 
percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g., 
impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" 
pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to 
hypoxemia, or 
    4. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken 
during exercise for a beneficiary who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen 
saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during 
exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during 
exercise when the beneficiary was breathing room air. You can find this information in Medicare's Local 
Coverage Determination (LCD): Oxygen and Oxygen Equipment (L33797). 
 
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 SACROILIAC (SI) JOINT INJECTIONS 
 
The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum 
and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of 
strain and/or pain. 
 
Indications for Sacroiliac (SI) Joint Injections: 
 
Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis 
and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint 
dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless 
conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. 
 
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. 
Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by 
the intra-articular injection of a small volume of local anesthetics of different durations of actions. A positive 
response should demonstrate initial pain relief greater than or equal to (> /=) 75% - 100% and the ability to 
perform previously painful maneuvers. Steroids may be injected in addition to the local anesthetic. 
 
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and 
potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that 
the SI joint is the source of pain in the lower back. The local anesthetic used for the procedure should not be 
billed. 
 
SI joint arthrography and/or therapeutic injection of an anesthetic/steroid should only be reported when 
imaging confirmation of intra-articular needle positioning with applicable radiological and/or fluoroscopic 
procedures have been performed. 
 
Limitations for Sacroiliac (SI) Joint Injections: 
 
If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for 
immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections would not be considered medically necessary. 
 
Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pain Management 
(L33622). 
 
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 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). 
 
Modifiers are used to identify therapy services whether or not financial limitations are in effect. When 
limitations are in effect, the Common Working File (CWF) tracks the financial limitation based on the presence 
of therapy modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code 
on the list of applicable therapy codes except as noted in section 20 of this chapter. Consult section 20 for the 
list of codes to which modifiers must be applied. These modifiers do not allow a provider to deliver services 
that they are not qualified and recognized by Medicare to perform. 
 
The claim must include one of the following modifiers to distinguish the discipline of the plan of care under 
which the service is delivered: 
 GN Services delivered under an outpatient speech-language pathology plan of care; 
 GO Services delivered under an outpatient occupational therapy plan of care; or, 
 GP Services delivered under an outpatient physical therapy plan of care.  
 
You can find this information in the Centers for Medicare and Medicaid Services Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.1. 
 
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 the quantity of test strips (code A4253) and lancets (code A4259) that are covered depends 
on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, 
regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. Coverage of testing 
supplies is based on the following guidelines: 
 
Usual Utilization 
 
For a beneficiary who is not currently being treated with insulin administrations, up to 100 test strips and up to 
100 lancets every 3 months are covered if the basic coverage criteria (1)-(2) (above) are met. 
 
For a beneficiary who is currently being treated with insulin administrations, up to 300 test strips and up to 300 
lancets every 3 months are covered if basic coverage criteria (1)-(2) (above) are met. 
 
High Utilization 
 
For a beneficiary who is not currently being treated with insulin administrations, more than 100 test strips and 
more than 100 lancets every 3 months are covered if criteria (a)  (c) below are met. 
 
For a beneficiary who is currently being treated with insulin administrations, more than 300 test strips and 
more than 300 lancets every 3 months are covered if criteria (a)  (c) below are met. 
 
    Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and 
supplies are met; and, 
 
    Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization 
guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes 
control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described 
above; and, 
 
    Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual 
utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen. 
 
 If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and 
necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria 
(a)  (c) are not met, the amount in excess will be denied as not reasonable and necessary. You can find this 
information in the Local Coverage Determination for Glucose Monitors (L33822). 
 
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 definitive drug testing is indicated when: 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical 
history. 
3. This test may also be used, when the coverage criteria of the policy are met AND there is no 
presumptive test available, locally and/or commercially, as may be the case for certain synthetic or 
semi-synthetic opioids. 
You can find this information in Local Coverage Determination (LCD) Drug Testing L34645. 
 
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 traction equipment is covered if the patient has orthopedic impairment requiring traction 
equipment which prevents ambulation during the period of use (Consider covering devices usable during 
ambulation; e.g., cervical traction collar, under the brace provision). You can find this rule in the the National 
Coverage Determination (NCD) - Durable Medical Equipment (DME) Reference List (280.1). 
 
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 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 $175 copayment for advanced imaging services, including CT scans. 
You can find this information on page 76 of the Plan's 2021 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $25 copayment for a specialist office visit. You can find this 
information on page 81 of the Plan's 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 say that hospital beds are covered only with a physicians prescription and sufficient documentation 
in the patients medical records to establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patients condition requires positioning of the body, e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or   
 
2. The patients condition requires special attachments that cannot be fixed and used on an ordinary bed.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.7. 
 
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 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 crown 
(D2750) and endodontic therapy (D3310), and you must pay a 50% coinsurance for each of these services. You 
can find this information on pages 4-91 and 4-92 of the Plans 2021 Evidence of Coverage (EOC).