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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
For Medicare purposes, a reasonable and necessary reduction mammoplasty may be indicated in the presence 
of significantly enlarged breasts and the presence of at least two of the following signs and/or symptoms when 
the breast hypertrophy and the symptoms and signs have been present for at least six months and have not 
responded to a reasonable non-surgical care program: 
 
    Upper back, shoulder and /or neck pain that appears to be directly correlated to the macromastia 
    Headache (cephalgia) when same can be directly attributed to the excessive breast weight and its effect on 
the neck and/or shoulders and other reasonable causes of a headache have been addressed/ruled out 
    Significant thoracic kyphosis which is felt to be directly correlated to the breast hypertrophy. 
    Chronic breast pain due to the excessive weight of the breasts. 
    Intertriginous maceration or infection of the inframammary skin refractory to usual dermatologic measures. 
    Shoulder grooving from supporting garment (bra strap). 
    Upper extremity paresthesia due to brachial plexus compressions syndrome secondary to the weight of the 
breasts being transferred to the shoulder strap area 
 
You can find this information in the Medicare Local Coverage Determination (LCD): Plastic Surgery 
(L35163). 
 
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 a $150 allowance is available towards the purchase of any other frame/lenses or contacts at 
either an in-network or out-of-network provider. You can find this information on pages A1-55 to A1-56 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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules say that payment may be made for a one-time ultrasound screening for AAA for beneficiaries who 
meet the following criteria:  
i. receives a referral for such an ultrasound screening from the beneficiarys attending physician, 
physician assistant, nurse practitioner or clinical nurse specialist;  
ii. receives such ultrasound screening from a provider or supplier who is authorized to provide covered 
ultrasound diagnostic services;  
iii. has not been previously furnished such an ultrasound screening under the Medicare Program; and  
iv. is included in at least one of the following risk categories--  
I. has a family history of abdominal aortic aneurysm;  
II. is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or  III. is a beneficiary who manifests other risk factors in a beneficiary category recommended for 
screening by the United States Preventive Services Task Force regarding AAA, as specified by 
the Secretary of Health and Human Services, through the national coverage determination 
process. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-04, Medicare Claims 
Processing Manual, Chapter 18, Section 110.2. 
 
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 state that therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet all the following criteria: 
a. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with 
each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of 
relief being consistent with the agent used); and 
b. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least consistent 
50% pain relief for at least three (3) months from the prior therapeutic procedure 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; and 
c. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established 
spinal pseudarthrosis, implanted electrical device) 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38773). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that modifiers HA through HZ are not covered. You can find this rule in the Centers for Medicare 
and Medicaid Services, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.4.2. 
 
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 state that Medicare covers these cyogenetic tests when they are reasonable and necessary for the 
diagnosis or treatment of the following conditions: 
 
    -Genetic disorders (e.g., mongolism) in a fetus; (See the Medicare Benefit Policy Chapter 15, "Covered 
Medical and Other Health Services," 20.1) 
    -Failure of sexual development; 
    -Chronic myelogenous leukemia; 
    -Acute leukemias lymphoid (FAB L1-L3), myeloid (FAB M0-M7), and unclassified; or 
    -Mylodysplasia 
 
You can find this information in National Coverage Determination (NCD): Cytogenetic Studies 190.3.  
 
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.
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 thermal ablation (radiofrequency or laser) will be considered medically reasonable and 
necessary for ablation of incompetent saphenous veins for the treatment of patients with symptomatic Clinical, 
Etiology, Anatomic, Pathophysiology (CEAP) clinical classification C2 to C6 disease. You can find this rule in 
the Local Coverage Determination (LCD) - Treatment of Chronic Venous Insufficiency of the Lower 
Extremities (L34924) - Effective December 27, 2020. 
 
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 oxygen reimbursement is a bundled payment. All options, supplies and accessories are 
considered included in the monthly rental payment for oxygen equipment. Oxygen rental is billed using the 
appropriate code for the provided oxygen equipment. Separately billed options, accessories or supply items will 
be denied as unbundling. Emergency or stand-by oxygen systems for beneficiaries who are not regularly using 
oxygen will be denied as not reasonable and necessary since they are precautionary and not therapeutic in 
nature. You can find this rule in 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. 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 65 to 66 of the Plan's 2023 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 neuropsychological testing does not rely on self-report questionnaires such as the 
Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression 
Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT) when 
questions of how brain damage or degenerative disease processes (e.g. right hemisphere CVA) may be 
affecting emotional expression or how significant emotional distress or mood impairment might be affecting 
cognitive function (e.g. question of presence of "pseudodementia") arise. You can find this information in 
Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
  
  Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 hearing aids will be reimbursed up to $3,000 once every 60 months when you see any 
licensed hearing provider in the United States. You can find this information on page 15 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 oxygen is coverable when medically necessary for patients with acute or chronic conditions, 
short- or long-term, when the patient exhibits hypoxemia. Patients exhibiting hypoxemia are defined using the 
clinical criteria below.  
 
1. Arterial PO2 (partial pressure of oxygen) at or below 55 mm Hg or arterial O2 (oxygen) saturation at or 
below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for patients who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when 
medically reasonable and necessary for patients who do not have a non-covered indication. 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 240.2. 
 
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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that isolation for active infectious disease should be coded only when the resident requires 
transmission-based precautions and single room isolation (alone in a separate room) because of active infection 
(i.e., symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or 
epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet 
transmission. Do not code this item if the resident only has a history of infectious disease (e.g., s/p MRSA or 
s/p C-Diff - no active symptoms). Do not code this item if the precautions are standard precautions, because 
these types of precautions apply to everyone. Standard precautions include hand hygiene compliance, glove 
use, and additionally may include masks, eye protection, and gowns. Examples of when the isolation criterion 
would not apply include urinary tract infections, encapsulated pneumonia, and wound infections. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Section O: Special Treatments Procedures, and Programs. 
 
The rules say that you should code for "single room isolation" only when all of the following conditions are 
met: 
 
1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that 
have been acquired by physical contact or airborne or droplet transmission. 
2.Precautions are over and above standard precautions. That is, transmission-based precautions (contact, 
droplet, and/or airborne) must be in effect. 
3.The resident is in a room alone because of active infection and cannot have a roommate. This means that the 
resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a 
similar active infection that requires isolation. 
4.The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.). 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Section O: Special Treatments Procedures, and Programs. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that modifier "-25" is used to facilitate billing of evaluation and management services on the day 
of a procedure for which separate payment may be made. It is used to report a significant, separately 
identifiable evaluation and management service by same physician on the day of a procedure. The physician 
may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, 
the patient's condition required a significant, separately identifiable evaluation and management service above 
and beyond the usual preoperative and postoperative care associated with the procedure or service that was 
performed. This circumstance may be reported by adding the modifier "-25" to the appropriate level of 
evaluation and management service. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2.A.8. 
 
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.