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 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 -58 was established to facilitate billing of staged or related surgical procedures done 
during the postoperative period of the first procedure. This modifier is not used to report the treatment of a 
problem that requires a return to the operating room. Modifier -79 reports an unrelated procedure by the same 
physician during a postoperative period. The physician may need to indicate that the performance of a 
procedure or service during a postoperative period was unrelated to the original procedure. 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. 
 
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 10% coinsurance of the approved amount for durable medical equipment 
(DME) and related medical supplies. You can find this information on page 61 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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. The criteria include being at high risk for 
hospitalization and require intensive care coordination. You can find this information on pages 56 to 57 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 Code E0118 describes a crutch substitute which can be either a device strapped to the lower 
leg with a platform or a device with wheels and a platform the beneficiary propels with their sound limb. You 
can find this rule in the Local Coverage Article Canes and Crutches - Policy Article A52459. 
 
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 $30 copayment for one pair of Medicare-covered standard glasses or 
contacts after each cataract surgery. You can find this information on page 102 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 the diagnosis of trigger points requires a detailed history and thorough physical examination. 
The following clinical symptoms may be present when making the diagnosis: 
 History of onset of the painful condition and its presumed cause (e.g., injury or sprain) 
 Distribution pattern of pain consistent with the referral pattern of trigger points 
 Range of motion restriction 
 Muscular deconditioning in the affected area 
 Focal tenderness of a trigger point 
 Palpable taut band of muscle in which trigger point is located 
 Local taut response to snapping palpation 
 Reproduction of referred pain pattern upon stimulation of trigger point 
The goal is to treat the cause of the pain and not just the symptom of pain. 
 
You can find this information in Local Coverage Determination (LCD): Trigger Point Injections (L35010). 
 
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. 
 
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 typically provided only for the treatment of nausea or as part of a comprehensive pain 
management program for the treatment of chronic pain. You can find this information on page 59 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 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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when all of 
the following criteria are met: 
 
- Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; and 
- Availability of a clinically valid test, based on published peer reviewed medical literature; and 
Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed test) or 
LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of analytical 
validity and clinical utility; and 
- Results of the testing must directly impact treatment or management of the Medicare beneficiary; and 
- For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases where a 
tiered approach/method is clinically available, testing would be covered ONLY for the number of genes or test 
that are reasonable and necessary to obtain necessary information for therapeutic decision making; and 
- Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic genetic 
testing for a disease should be performed once in a lifetime.) Exceptions include clinical scenarios whereby 
repeat testing of somatically-acquired mutations (for example, pre- and post- therapy) may be required to 
inform appropriate therapeutic decision-making. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): Molecular Pathology Procedures (L35000). 
 
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 genetic testing for hereditary cardiovascular disease will be considered medically reasonable and 
necessary if: 
 
The patient has rigorous disease-appropriate phenotyping to establish clinical diagnosis or suspected diagnosis 
for which the test results would directly impact the management of the patients condition, prior to ordering the 
test 
AND 
The evidence for the gene-disease association is evaluated by the evidence-based, transparent, peer-reviewed 
process of the National Institutes of Health (NIH) sponsored Clinical Genome Resource (ClinGen) and is 
determined to demonstrate actionability in clinical decision making, meeting all bulleted metrics: 
Disease severity of sudden death, possible death or major morbidity, modest morbidity 
Substantial or moderate evidence of a >40% likelihood of disease 
Substantial or moderate evidence of a highly effective or moderately effective intervention 
The nature of intervention is either low risk/medically acceptable/low intensity intervention or moderately 
acceptable/risk/intensive interventions, 
AND 
Clinical validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory evidence 
NOT being reported as disputed or refuted. 
Limitations 
 
The following are considered not medically reasonable and necessary: 
 
A genetic test where either analytical validity, clinical validity, or clinical utility has not been established. 
Genetic testing in patients who do not demonstrate the disease-appropriate phenotype of the gene-disease 
association. 
Genetic testing of asymptomatic patients. 
Genetic testing solely for purposes of proband identification. Genetic testing with family history as the only indication. 
Gene tests for cardiovascular disease are considered germline testing, and therefore only permitted once per 
beneficiarys lifecycle. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Genetic Testing for 
Cardiovascular Disease (L39084). 
 
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 state that Epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following requirements are met: 
o History, physical examination, and concordant radiological image-based diagnostic testing that 
supports one of the following
5
: 
 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 
 Post-laminectomy syndrome, or 
 Acute herpes zoster associated pain. 
 
o 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 used at each follow-up for 
assessment of response. 
 
o 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 this information in Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L36920). 
 
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 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 the Local Coverage Determination (LCD): Pain Management (L33622). 
 
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 molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage when ALL 
of the following criteria are met: 
 Alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are 
unavailable or results are clearly equivocal; AND 
 Availability of a clinically valid test, based on published peer reviewed medical literature; AND 
 Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if LDT (lab developed 
test) or LDT protocol or FDA modified test(s) the laboratory documentation should support assay(s) of 
analytical validity and clinical utility; AND 
 Results of the testing must directly impact treatment or management of the Medicare beneficiary; AND 
 For testing panels, including but not limited to, multiple genes or multiple conditions, and in cases 
where a tiered approach/method is clinically available, testing would be covered ONLY for the number 
of genes or test that are reasonable and necessary to obtain necessary information for therapeutic 
decision making; AND 
 Individual has not previously received genetic testing for the disease/condition. (In general, diagnostic 
genetic testing for a disease should be performed once in a lifetime.) Exceptions include clinical 
scenarios whereby repeat testing of somatically-acquired mutations (for example, pre- and post- 
therapy) may be required to inform appropriate therapeutic decision-making. You can find these rules in Local Coverage Determination (LCD) MOLECULAR Pathology Procedures 
L35000 
 
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 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).  
 
The rules say that progressive lenses (V2781) will be denied as non-covered. You can find this rule in the 
Local Coverage Article for Refractive Lenses - Policy Article (A52499). 
 
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 you have a $200 allowance per year for routine prescription eyewear. You can find this 
information on pages 112 and 113 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 state that Next Generation Sequencing is considered medically necessary for specific diagnosis 
codes. You can find this rule in the Medicare National Coverage Determinations, Transmittal 215. 
 
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 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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 20 one-way routine transportation trips per calendar year. You can find this information on page 
94 of the Plans 2022 Evidence of Coverage (EOC).