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 a panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. This rule is found in Local Coverage Article: 
Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification 
Testing (A58761). 
 
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 for services performed on or after January 21, 2020, Medicare will now provide limited
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage,
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause,
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may
be provided by a physician in accordance with state requirements, or by physician assistants, nurse
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements.
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician,
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage
Determinations Manual, Section 30.3.3.
The rules say effective for services performed on and after October 24, 2006, the Centers for Medicare &
Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy
devices and any related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social
Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic
infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these
conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin
and/or subcutaneous tissues. You can find this in the National Coverage Determination (NCD): Infrared
Therapy Devices (270.6).
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 offers additional coverage for acupuncture beyond what is covered by Medicare. This benefit
covers acupuncture for chronic low back pain. You can find this on page 63 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 state that Electro-acupuncture devices, including but not limited to P-STIM devices, are applied 
behind 
the ear using an adhesive and/or with needles inserted into the patients ear (similar to acupuncture). Providers 
are inappropriately coding electro-acupuncture devices as implantable neurostimulators (L8679 - implantable 
neurostimulator, pulse generator, any type), which are Medicare-covered devices that require surgical 
implantation into the central nervous system or targeted peripheral nerve, and are usually implanted via 
procedures performed in operating rooms. 
 
The rule say that electro-acupuncture devices used for stimulation of auricular acupuncture points are non-
covered. These rules are found in Local Coverage Article Billing and Coding: Auricular Peripheral Nerve 
Stimulation (Electro-Acupuncture Device) 
(A55240) and CMS document MLN SE20001, Incorrect Billing of HCPCS L8679-Implantabel 
Neurostimulator, Pulse 
generator, Any Type. 
 
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 the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $30 copay for certain wound care services and a $300 copay for all other services in an outpatient hospital. You can find this information on page 81 of the Plan's 2022 Evidence of Coverage (EOC). Some clinics where you see providers may be owned by a hospital. When you receive services at these clinics you may have higher out-of-pocket costs because hospital-owned clinics may bill you for both the provider you see, and for the use of the facility the provider is in. You can find this information on page 227 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 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 a bacterial urine culture is a laboratory procedure performed on a urine specimen to establish 
the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a 
urine culture. A urine culture may also be used as part of the evaluation and management of another related 
condition. You can find this information at National Coverage Determination (NCD) Urine Culture, Bacterial 
190.12. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, 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. 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 30 to 31 of the Plan's 
2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say 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 $60 copayment for acupuncture for chronic low back pain received from a specialist out-of-network. You can find this information on pages 4-7, 4-56 and 4-57 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 state that a panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. This rule is found in Local Coverage Article: 
Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification 
Testing (A58726). 
 
 
 
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 treatment for lower urinary-tract symptoms (LUTS)/benign prostatic hypertrophy (BPH) 
treatment will be considered reasonable and necessary when performed ONCE in patients with the following: 
 
1. Indications including ALL the following:  
   1. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
   2. Persistent moderate to severe symptoms despite maximal medical management including ALL the 
following: 
      1. International Prostate Symptom Score (IPSS) equal to or greater than 12 
      2. Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 
cc) 
      3. Failure, contraindication or intolerance to at least 3 months of conventional medical therapy for 
LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
2. Only treatment using a Food and Drug Administration (FDA) approved/cleared device will be considered 
reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Transurethral Waterjet Ablation of 
the Prostate (L38549). 
 
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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
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 health 
Plan contract says that you can receive your care from either a network provider or an out of network provider. 
While you can get your care form an out of network provider, the provider must be eligible to participate in 
Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the 
full cost of the services you receive. You can find this information on page 3-4 of the plans 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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, 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. The Plan 
contract says that virtual care (telehealth services), enrollee's must use in-network providers. Virtual care 
provided by an out-of-network provider is not covered. This information can be found on page 122 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 say that Respiratory (RP) and Pneumonia (PNP) Panels will only be covered when targeted testing is 
not appropriate AND according to the following additional criteria: 
- For immune-competent patients, at least 1 of the following must apply: 
o Testing is ordered by a clinician specialist in Infectious Diseases or Pulmonology for a patient 
with severe and established underlying respiratory pathology (i.e., severe asthma, chronic 
obstructive pulmonary disease (COPD), cystic fibrosis, pulmonary fibrosis, radiation therapy to 
the lung) AND treatment with antibiotics may be indicated according to established guidelines.  
o The patient is seriously or critically ill or at imminent risk of becoming seriously or critically 
ill (as defined by the American Hospital Association's "General Guide for the Release of 
Information on the Condition of Patients") as a result of a presumed respiratory infection AND 
the patient is being treated in an appropriate critical care facility. 
- For immune-suppressed patients: Testing is ordered by a clinician specialist in 1 of the following: 
Infectious Diseases, Pulmonology, Oncology, Transplant OR the patient is being managed in an 
appropriate critical care facility. 
- For ALL patients: Only 1 of the following panels - RP OR PNP- will be covered for a given patient for 
the same clinical indication. The PNP should be prioritized in the evaluation of pneumonia from lower 
respiratory tract specimens (i.e., bronchoalveolar lavage samples [BALs]). For the purposes of repeat 
panel testing for the same clinical indication, RP and PNP will be considered as equivalent tests, such 
that if criteria for repeat testing are met (as defined above), a clinician may choose to perform the repeat 
test using the PNP, even if the original test was performed using the RP. 
 
You can find this rule in the Local Coverage Determination for Molecular Diagnostics (MolDX): Molecular 
Syndromic Panels for Infectious Disease Pathogen Identification Testing, L39044.  
 
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 during the rental of a TENS unit, supplies for the unit are included in the rental allowance; 
there is no additional allowance for items such as electrodes, lead wires, and batteries. You can find this 
information in the Local Coverage Article for Transcutaneous Electrical Nerve Stimulators (TENS) - Policy 
Article (A52520). 
 
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 proton beam therapy will be considered medically reasonable and necessary for the 
following conditions: 
 Benign or malignant conditions otherwise not suitable for intensity modulated radiation therapy (IMRT) 
or 3- dimensional conformal therapy involving the base of the skull or axial skeleton, including but not limited 
to chordomas and chondrosarcomas. 
 Solid tumors in children up to age 18. 
 Benign or malignant central nervous system tumors to include primary and variant forms of 
medulloblastoma, astrocytoma, glioblastoma, arteriovenous malformations, acoustic neuroma 
craniopharyngioma, benign and atypical meningiomas and pineal gland tumors. 
 Intraocular melanomas 
Proton beam therapy will be considered as medically reasonable and necessary for certain other conditions not 
listed above, as long as the following criteria are met: 
Either #1, #2, or #3 must be present and 
Either #4 or #5 must be present and 
#6 must always be present. 
1.  When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with 
other indicated methods 
2.  When there is a reason to believe that doses generally thought to be above the level otherwise attainable 
with other methods might improve control rates 
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 
4.  For the treatment of primary lesions, the intent of treatment must be curative 
5.  For the treatment of metastatic lesions, there must be 
1. the expectation of a long-term benefit (greater than 2y) that could not have been attained with 
conventional therapy 
2. the expectation of a complete eradication of the metastatic lesion that could not have been safely 
accomplished with conventional therapy, as evidenced by a dosimetric advantage for proton beam radiotherapy 
over other forms of radiation therapy 
6.  The patients record demonstrates why Proton beam radiotherapy is considered the treatment of choice for the individual patient. Specifically, the record must address the lower risk to normal tissue, the lower risk of 
disease recurrence, and the advantages of the treatment over IMRT or 3-dimensional conformal therapy. 
Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained. 
 
You can find this information in the Local Coverage Determination (LCD): Proton Beam Radiotherapy 
(L33937). 
 
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 KX modifier should be appended to Durable Medical Equipment (DME) claims to 
indicate that Medicare coverage requirements have been met.  You can find this rule at Centers for Medicare 
and Medicaid Services, Local Coverage Determination L33791 entitled "Walkers" and L33736 entitled 
"Commodes," as well as Local Coverage Article A52457 entitled "Ankle-Foot/Knee-Ankle-Foot Orthoses-
Policy Article." 
 
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 test panel is a single test with multiple components and is characterized by a single unit 
of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact 
that the test reports multiple individual pathogens and/or targets. If additional organisms are not included in a 
panel, testing for those organisms separately may be reasonable and necessary when ordered in addition to the 
panel and supported by documentation in the medical record. You can find this rule in the Local Coverage 
Article Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen 
Identification Testing, A58720. 
 
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.