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 ConfirmMDx is covered for males aged 40 to 85 years old that have undergone a previous 
cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent 
or elevated cancer risk factors. This rule is found in Local Coverage Determination (LCD: MolDX: 
ConfirmMDx Epigenetic Molecular Assay (L36327). 
 
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 administration for ranibizumab, ranibizumab-nuna, aflibercept, brolucizumab-dbll or 
faricimab-svoa must be billed on the same claim as the drug, with CPT code 67028 (intravitreal injection of a 
pharmacologic agent). You can find this rule at Local Coverage Article (LCA) A52451: Billing and Coding: 
Ranibizumab, Aflibercept and Brolucizumab-dbll and Faricimab-svoa (eff. 1/1/20). 
 
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 VA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) based on symptom 
onset, and documented by advanced imaging  (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) 
1-3,10,25,27
 
b. Symptomatic (ONE):  
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score  8) 
4-7
 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-
surgical management (NSM)
10 
(ONE):  
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5) (with  2 of the following):  
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17 
c. Continuum of care
10 
(Both)  
i. All patients presenting with VCF should be referred for evaluation of BMD and 
osteoporosis education for subsequent treatment as indicated.  
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program.  
You can find this rule in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation (PVA) 
for Osteoporotic Vertebral Compression Fracture (VCF) L34106. 
 
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 all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiarys specific medical problem. This rule is found in the Code of Federal Regulations (CFR), 410.32. 
 
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 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 also says that it will cover hearing aids when purchased from the Plan's designated hearing aid vendor.  
Any hearing aids ordered through providers other than the Plan's designated hearing aid vendor are not 
covered. You can find this information on page 4-92 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 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 an active trigger point has pain at rest, has pain on palpitation, has radiation of pain, and has 
a local twitch response. Trigger point injections are indicated in symptomatic trigger points. The history of 
onset of the painful condition and its presumed cause, location, duration, failed therapies and recommendations 
for injection therapy of each clearly delineated muscle must be in the patients chart and made available to 
Medicare upon request. The goal is to treat the cause of the pain and not just the symptom of pain. 
 
Limitations 
1. Trigger point injections accompanied by appropriate adjunctive care should provide moderate-to-long 
term benefits. There is no peer-reviewed literature to substantiate more than four trigger point injections 
in a year. 
2. Prolotherapy is not covered by Medicare. If prolotherapy is billed using trigger point therapy codes it 
will be considered not reasonable and necessary. 
You can find this rule in Local Coverage Determination (LCD) Trigger Point Injections L37635 . 
 
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 some International Classification of Diseases-10th Version-Clinical Modification (ICD-10-
CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.  If no 
bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.  If 
the side is not identified in the medical record, assign the code for the unspecified side. You can find this 
information in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
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 diagnostic breath analyses are tests performed to measure either the hydrogen or carbon 
dioxide content of the breath after the ingestion of certain compounds. The analyses are performed to diagnose 
certain gastrointestinal disease states. 
 
Lactose breath hydrogen testing is covered to detect lactose malabsorption. However, lactulose breath 
hydrogen for diagnosing small bowel bacterial overgrowth (SBO) and measuring small bowel transit time is 
excluded from coverage. You can find this in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-03, National Coverage Determinations Manual, Section 100.5. 
 
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 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 also say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter X(F). 
 
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 covers a lung cancer screening counseling and shared decision-making visit, and for appropriate beneficiaries, annual screening for lung cancer with LDCT, as an additional preventive service benefit under the Medicare program when certain criteria are met. For purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria: 
1. Age of 55-77 years, 
2. Absence of signs/symptoms of lung cancer, 
3. Tobacco smoking history of at least 20 pack-years (one pack-year equates to smoking one pack/day for one year, 
4. Current smoker or former smoker who quit within the last 15 years. 
All these criteria must be clearly documented in the medical record, including the actual pack-year smoking history as a number. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14).
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 payment under the fee schedule for ambulance services includes a base rate payment plus a
separate payment for mileage. This payment covers both the transport of the beneficiary to the nearest
appropriate facility and all items and services associated with such transport. Payment for items and services,
such as oxygen, is included in the fee schedule payment. Ambulance suppliers must accept the Medicare
allowed charges as payment in full and may not bill or collect from the beneficiary any amount other than the
unmet cost-sharing. You can find this rule at 42 CFR Section 414.610 and in the Centers for Medicare and
Medicaid Service, Internet-Only Manual, Medicare Claims Processing Manual, Chapter 15, Section 20.1.1.
The rules state that an ambulance must have customary patient care equipment and first aid supplies, including
reusable devices and equipment such as backboards, neckboards, inflatable legs, and arm splints. These are all
considered part of the general ambulance service and payment for them is included in the payment rate for the
transport. You can find this rule in Medicare Benefit Policy Manual Chapter 10, Section 10.1.5.
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 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.
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 Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are: 
1. blood-clotting factors; 
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients; 
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs; 
6. oral anti-emetics used in certain situations; 
7. drugs treated as supplies during an outpatient hospital procedure; and 
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3.
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 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 will cover screening for HCV with the appropriate U.S. Food and Drug Administration (FDA)-approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act regulations, when ordered by the beneficiary's primary care physician or practitioner within the context of a primary care setting, and performed by an eligible Medicare provider for these services, for beneficiaries who meet either of the following conditions: 
1. A screening test is covered for adults at high risk for HCV infection. "High risk" is defined as persons with a current or past history of illicit injection drug use; and persons who have a history of receiving a blood transfusion prior to 1992. Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test. 
2. A single screening test is covered for adults who do not meet the high risk definition above, but who were born from 1945 through 1965.
You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 210.13.
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 Centers for Medicare and Medicaid Service (CMS) has established units of service edits referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. Claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are "per day edits based on policy." Codes with an MAI of "2" have been rigorously reviewed and vetted within CMS and obtain this MAI designation because units of service on the same date of service (DOS) in excess of the MUE value would be considered impossible because it was contrary to statute, regulation, or subregulatory guidance. 
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(V).
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 page 8 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 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 page 43 of the Plan's 2022 Evidence of Coverage.