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 percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ) for the treatment 
of back pain is indicated for the treatment of SIJ pain for patients with low back/buttock pain who meet all of 
the following criteria: 
 
a) Have undergone and failed a minimum six months of intensive non-operative treatment that must include 
medication optimization, activity modification, and active physical therapy; 
b) Patients report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized 
over the posterior SIJ, and consistent with SIJ pain; 
c) Localized tenderness with palpation of the posterior SIJ in the absence of tenderness of similar severity 
elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and other obvious sources for their pain do not exist; 
d) Positive response to the thigh thrust test OR compression test AND 2 of the following additional provocative 
tests: Gaenslens test, Distraction test, Patricks sign; 
e) Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia); 
f) Diagnostic imaging studies that include ALL of the following: 
 
1. Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions 
(e.g. tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ 
fusion; 
2. Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis; 
3. Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that 
can be causing low back or buttock pain; 
 
g) At least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-
guided, contrast-enhanced SIJ injection on two separate occasions. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous minimally 
invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain (L36000). 
 
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 pays for ambulance services that meet certain origin and destination requirements. 
In order to meet this requirement, the ambulance supplier must transport the patient for whom the emergency 
call was placed. If an ambulance responds to a call but does not transport the person for whom the call was 
placed, Medicare does not pay for the service. You can find this rule at 42 CFR Section 410.40(f) and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 10, Section 10. 
 
The rules also say that model payments for Transport to an Alternative Destination and Treatment in Place 
interventions will be made available for Medicare Fee-for-Service beneficiaries only. You can find this rule at 
https://innovation.cms.gov/innovation-models/et3/faq#multi_payer. 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
   a. Patient has: 
 
   i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
   ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
   iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
   b. The diagnostic laboratory test using NGS must have: 
 
   i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
   ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
   iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in the National Coverage Determination (NCD) for Next Generation Sequencing (NGS) 
(90.2). 
 
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 Advantage (MA) plans, for reasons of cost, may wish to provide a required 
original Medicare transplant service at a distant location (further away than the normal community patterns of 
care for that service), even though provision of the service is available locally (within the service area), 
consistent with community patterns of care for original Medicare beneficiaries who reside in the service area. 
 
When providing an original Medicare service at a more distant location, farther away than the normal 
community patterns of care for transplants, the MA plan must ensure that the distant location provides at least 
the same quality and timeliness of services as at the local providers of this service. In this circumstance, the 
MA plan must provide reasonable transportation and lodging for the enrollee and a companion while in the 
distant location for medical care. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section  
10.11. 
 
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 their Primary Care Physician (PCP) 
to receive care from 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 41 to 42 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 an epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following three (3) requirements are met: 
1. History, physical examination, and concordant radiological image-based diagnostic testing supporting one 
of the following: 
a. Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing 
foraminal or central spinal stenosis; OR 
b. Post-laminectomy syndrome; OR 
c. Acute herpes zoster associated pain 
AND 
2. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of 
life or function. An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale must be repeated at each follow-up for assessment of response. 
AND 
3. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster 
refractory to conservative management where a four (4) week wait is not required 
You can find these rules in the Local Coverage Determination (LCD) for 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 state that high frequency chest wall oscillation devices (HFCWO) (E0483) are covered for 
beneficiaries who meet: 
 
Criterion 1, 2, or 3, and 
 
Criterion 4 
 
There is a diagnosis of cystic fibrosis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses). 
 
There is a diagnosis of bronchiectasis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses) which has been confirmed by a high resolution, spiral, or standard CT scan and which is 
characterized by: 
 
Daily productive cough for at least 6 continuous months; or 
 
Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. 
 
Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis 
of bronchiectasis do not meet this criterion. 
 
The beneficiary has one of the following neuromuscular disease diagnoses (refer to the ICD-10 code list in the 
LCD-related Policy Article for applicable diagnoses): 
Post-polio 
Acid maltase deficiency 
Anterior horn cell diseases 
Multiple sclerosis 
Quadriplegia 
Hereditary muscular dystrophy 
Myotonic disorders 
Other myopathies 
Paralysis of the diaphragm 
 There must be well-documented failure of standard treatments to adequately mobilize retained secretions. 
 
If all of the criteria are not met, the claim will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) High Frequency Chest Wall 
Oscillation Devices L33785. 
 
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 If a plan sponsor uses a tiered cost-sharing structure to manage its drug benefits, it must establish  
and maintain reasonable and complete exceptions procedures that permit enrollees to obtain a non-preferred 
drug in a higher cost-sharing tier at the more favorable cost-sharing terms applicable to alternative drugs in a 
lower cost-sharing tier. Plans are permitted to limit the availability of tiering exceptions to applicable cost-
sharing tiers containing the same type of alternative drug(s) for treating the enrollees condition. Specifically,  
the following limitations may be applied by the plan:  
 Brand name drugs are eligible for tiering exceptions to the lowest applicable cost-sharing associated with 
brand name alternatives. Biological products are eligible for tiering exceptions to the lowest applicable cost-
sharing associated with biological alternatives.  
 Non-preferred generic drugs are eligible for tiering exceptions to the lowest applicable cost sharing associated 
with alternatives that are either brand or generic drugs. Plans are not required to offer tiering exceptions for 
brand name drugs or biological products at the cost-sharing level of alternative drugs, where the alternatives 
include only generic or authorized generic drugs.  
If a plan maintains one or two specialty tiers, as defined in 42 CFR Section 423.104, the plan may design its 
exception process so that Part D drugs on the specialty tier(s) are not eligible for tiering exception(s) to non-
specialty tiers. However, plans with two specialty tiers must permit tiering exception requests for drugs on the 
higher cost-sharing specialty tier to the lower cost-sharing specialty tier. You can find this information in the 
Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance; 40.5.1  
Tiering Exceptions. 
 
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 drugs in the Plan's Specialty Tier are not eligible for this type of exception. The Plan does not 
lower the cost-sharing amount for drugs in this tier. You can find this information in Chapter 4 on page 109 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says up to 60 one-way trips, combined in and out-of-network, are covered each year (limited to ground 
transportation only).  You can find this information in Chapter 4 on page 4-83 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 Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 
 
The rules say that irreparable wear refers to deterioration sustained from day-to-day usage over time and a 
specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration 
the reasonable useful lifetime of the equipment.  
 
The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the 
absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of equipment, 
but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment is 
delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair 
up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the 
beneficiary. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-04, Medicare Benefit Policy Manual, Chapter 15, 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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. 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 290(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 for people with diabetes who have severe diabetic foot disease: One pair per 
calendar year of therapeutic custom-molded shoes are covered (including inserts provided with such shoes) and 
two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-
customized removable inserts provided with such shoes). Coverage includes the fitting. You can find this 
information on page A1-26 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 state that only one screening mammogram is covered for women ages 35 to 39. This information is 
found in the Medicare Claims Processing Manual Chapter 18, Section 20 - Mammography Services (Screening 
and Diagnostic). 
 
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). 
 
Medicare rules state that for Home Health services, a beneficiary can be covered for an unlimited number of 
nonoverlapping periods of care. For periods of care beginning on or after January 1, 2020, the duration of a 
period is 30 days. Periods of care may be shorter than 30 days. This rule is found in the Medicare Claims 
Processing Manual, Chapter 10, Section 1.5. 
 
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 Gastrointestinal Pathogen (GIP) testing is limited to no more than 5 bacterial pathogen 
targets when not testing for Clostridium difficile. Testing for 6-11 pathogens is covered when there is a clinical 
concern for Clostridium difficile colitis, and Clostridium difficile is one of the pathogens being tested. You can 
find this rule the Local Coverage Determination (LCD) - Foodborne Gastrointestinal Panels Identified by 
Multiplex Nucleic Acid Amplification Tests (NAATs) (L37766). 
 
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.