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 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 $350 copayment for Medicare-covered outpatient hospital surgery 
services and a $20 copayment for all other Medicare-covered outpatient hospital services. You can find this 
information in Chapter 4 on page 96 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 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 20% coinsurance for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information in Chapter 4 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 cardiovascular nuclear imaging is indicated for the following: 
 
1. Assessment of the functional and prognostic importance of angina; 
2. Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by 
drugs, bundle branch block, or left ventricular hypertrophy; 
3. Assessment of congenital anomalies of coronary arteries; 
4. Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with 
known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a 
revascularization procedure within the past two years; 
5. Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed 
heart failure or left ventricular systolic dysfunction; 
6. Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary 
angiography are not planned; 
7. Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other 
re-perfusion procedures; 
8. Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; 
9. Assessment of congenital anomalies of coronary arteries; 
10. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or 
perioperative management 
11. Evaluation of ventricular function in patients with non-ischemic myocardial disease; 
12. Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a 
determination of whether to implant a defibrillator or biventricular pacemaker; 
13. Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., 
adriamycin). 
 
You can find this rule in the Local Coverage Determination (LCD) - Cardiovascular Nuclear Medicine 
(L33560) - Effective October 1, 2019. 
 
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 $325 copayment for same-day outpatient surgery in an outpatient 
hospital facility. You can find this information in Chapter 4 on page 101 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 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. The Plan 
contract also says that covered drugs include drugs that usually are not self-administered by the patient and are 
injected or infused while you were getting physician, hospital outpatient, or ambulatory surgical center 
services. You can find this information on page 111 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 the date of service (DOS) for laboratory tests generally must be the date the specimen was 
collected; however, an exception is made for molecular pathology tests performed by a laboratory other than a 
blood bank. This requires that the DOS be reported as the date the testing was performed when: the test was 
performed following a hospital outpatient's discharge from the hospital outpatient department; the specimen 
was collected from a hospital outpatient during an encounter; and, it was medically appropriate to have 
collected the sample from the hospital outpatient during the hospital outpatient encounter. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 16, Section 40.8. 
 
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.
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 various Hyaluronan preparations (viscosupplementation) for intra-articular injections of the 
knee are considered reasonable and necessary when ALL of the following criteria documented in the medical 
record are met: 
 
1. Symptomatic osteoarthritis OA of the knee. Pain that interferes with functional activities (such as, 
ambulation and prolonged standing). 
 
2. The diagnosis is supported by radiographic evidence of OA of the knee, for example, joint space narrowing, 
subchondral sclerosis, osteophytes, and subchondral cysts. 
 
3. Trial and failure or contraindication of at least 3 months of conservative therapy: 
 
    -Non-pharmacologic therapy (e.g., physical therapy, exercise, weight management, self-management 
programs, knee brace, cane) 
    -Pharmacologic therapy (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) (oral, 
topical), topical capsaicin) 
 
4. Failure of or contraindication to intra-articular glucocorticoid injections. 
 
You can find this information in Local Coverage Determination (LCD): Hyaluronic Acid Injections for Knee 
Osteoarthritis (L39260). 
 
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 medically accepted off-label uses for Food and Drug Administration 
(FDA) approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of 
compendia which define if a use is medically accepted. The off-label use must be supported in one or more of 
these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one 
or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or 
equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state 
to be reasonable and necessary. You can find these rules and the list of the Medicare-recognized compendia in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 50.4.5. 
 
The rules say that erythropoiesis stimulating agents (ESA) treatment is not reasonable and necessary for 
beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their 
underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. 
These conditions include: 
 Any anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron 
deficiency, hemolysis, bleeding, or bone marrow fibrosis; 
 The anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML), 
or erythroid cancers; 
 The anemia of cancer not related to cancer treatment; 
 Any anemia associated only with radiotherapy; 
 Prophylactic use to prevent chemotherapy-induced anemia; 
 Prophylactic use to reduce tumor hypoxia; 
 Patients with erythropoietin-type resistance due to neutralizing antibodies; and 
 Anemia due to cancer treatment if patients have uncontrolled hypertension. 
 
Local Medicare Administrative Contractors may continue to make reasonable and necessary determinations on 
all other uses of ESAs not specified in this National Coverage Determination. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determination for Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic 
Conditions, 110.21. 
 
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 a PCD coded as E0650 or E0651 is covered for the treatment of chronic venous stasis ulcers 
(CVI) for enrollees with swelling in the affected leg, one of more stasis ulcers, and a lack of healing after a six-
month trial of conservative therapy. A PCD coded as E0652 is not covered for the treatment of CVI even if the 
criteria in this section are met. Claims will be denied as not reasonable and necessary. You can find this 
information in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). 
 
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 a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily 
medical in nature. This rule is found in Local Coverage Article Wheelchair Options/Accessories - Policy 
Article (A52504). 
 
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 page 124 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 in Chapter 3 on pages 46 to 48 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 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 $40 copayment for physician/practitioner services, including doctor's 
office visits, and a $105 copayment for outpatient diagnostic tests and therapeutic services and supplies. You 
can find this information in Chapter 4 on page 43 and 58 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 the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: stress fracture, spondylosis, infection (e.g., discitis), tumor (e.g., osteoid osteoma),     
analyze blood flow to an organ, as in the case of myocardial viability, differentiate ischemic heart disease from 
dilated cardiomyopathy. 
 
Indications and Limitations of Coverage 
 
Frequency limitations: Medicare Administrative Contractor discretion. 
 
In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT 
that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET 
performed to evaluate myocardial viability. You can find this rule in the National Coverage Determination 
(NCD)-220.12, Single Photon Emission Computed Tomography (SPECT). 
 
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). 
 
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 you have a $175 vision allowance for routine contact lenses or eyewear every year. The contract 
also says this benefit is administered on a rolling calendar year since your last date of service. You can find this 
information on page 119 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 repeat ESI when the first injection directly and significantly provided improvement of the 
condition being treated may be considered medically reasonable and necessary when the medical record 
documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using SAME scale for at least three months. You can find this information in the Local Coverage 
Determination (LCD): Epidural Steroid Injections for Pain Management (L39240). 
 
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.