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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules state that inpatient routine services in a hospital or skilled nursing facility generally are those services 
included in by the provider in a daily service charge--sometimes referred to as the "room and board" charge. 
Routine services are composed of two board components; (l) general routine services, and (2) special care units 
(SCU's), including coronary care units (CCU's) and intensive care Units (ICU's). Included in routine services 
are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, 
psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not 
customarily made. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 15, Provider Reimbursement Manual, Chapter 22, 2202.6. 
 
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 diagnostic laboratory test using NGS must have: 
 
1. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
2. an FDA-approved or -cleared indication for use in that patients cancer; and, 
3. 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 Medicare National Coverage Determination (NCD) for Next Generation 
Sequencing (NGS), Section 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 TAVR is covered for the treatment of symptomatic aortic valve stenosis when furnished 
according to a Food and Drug Administration (FDA)-approved indication and when all of the following 
conditions are met: 
 
    The procedure is furnished with a complete aortic valve and implantation system that has received FDA 
premarket approval (PMA) for that system's FDA approved indication. 
 
    The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-
disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication 
across medical specialties to offer optimal patient-centered care. The heart team includes the following: 
        Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis 
who have: 
            independently examined the patient face-to-face, evaluated the patients suitability for surgical aortic 
valve replacement (SAVR), TAVR or medical or palliative therapy; 
            documented and made available to the other heart team members the rationale for their clinical 
judgment. 
        Providers from other physician groups as well as advanced patient practitioners, nurses, research 
personnel and administrators. 
 
    The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-
operative technical aspects of TAVR. 
 
You can find this information in the National Coverage Determination (NCD) Transcatheter Aortic Valve 
Replacement (TAVR) 20.32. 
 
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 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 20% coinsurance for each covered Medicare Part B prescription drug. 
You can find this information in Chapter 4 on pages 4-27 to 4-29 of the Plan's 2021 Evidence of Coverage 
(EOC). 
 
The Plan contract says that enrollees must pay 20% coinsurance for each covered medical supply, $20 
copayment for each covered non-radiological diagnostic test, and $110 copayment for each covered 
radiological diagnostic test. You can find this information in Chapter 4 on pages 4-30 to 4-33 of the Plans 
2021 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay $30 copayment for services obtained from a specialist. You can 
find this information in Chapter 4 on pages 4-41 to 4-46 of the Plans 2021 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 per Medicare regulations, contraceptive devices or medications are not allowed for payment. 
For this reason the service, 58300, insertion of IUD has an "N" status in the Medicare Physician Fee Schedule, 
which means the service cannot be covered when billed to Medicare. 
 
Coverage for this method of treatment must be reasonable and necessary for the diagnosis, or treatment of 
illness, or to improve the functioning of the patients clinical condition, the standard of medical practice 
regarding the effectiveness of the IUD for the diagnosis and condition and meet all other applicable Medicare 
statutory and regulatory requirements. 
 
The patients medical record must clearly document the specific clinical circumstances supporting the medical 
necessity for services included within this Article. 
 
Evaluation to include abnormal uterine bleeding, 
Evaluation should not be performed without complaint of post-menopausal bleeding, 
Evidence of transvaginal ultrasound on file with documented stripe greater than 4mm. 
Pathology biopsy report: 
       1.  Simple/benign hyperplasia: a progesterone IUD is a reasonable treatment option. 
            -A Copper IUD is not a reasonable treatment option. 
       2. EIN/complex EH: documentation supports patient is a poor surgical candidate. Current nonsurgical            
management options are limited to hormonal therapy. 
 
You can find this rule at the Medicare Local Coverage Article (LCA)- A55951, Billing and Coding: 
Endometrial Hyperplasia Treatment with Intrauterine Device (Hormone-Eluting). 
 
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 tumor treatment field therapy is covered for the treatment of newly diagnosed Glioblastoma 
Multiforme (GBM) only when all of the following criteria are met: 
1. The beneficiary has histologically confirmed (World Health Organization (WHO) grade IV astrocytoma), 
newly diagnosed, supratentorial GBM; and, 
2. The beneficiary has received initial treatment with maximal debulking surgery (when feasible), followed by 
chemotherapy and radiotherapy; and, 
3. Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant chemotherapy 
or radiotherapy, whichever is later; and, 
4. The beneficiary has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) 
criteria; and, 
5. The beneficiary has a Karnofsky Performance Score (KPS) of at least 70; and, 
6. The beneficiary will use TTFT for an average of 18 hours per day. 
 
You can find this rule in the Local Coverage Determination (LCD) for Tumor Treatment Field Therapy 
(TTFT), L34823. 
 
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 $40 copayment for all other podiatry services per visit. You can find this 
information in Chapter 4 on page 84 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 if the beneficiary accepts the purchase option, the DME MAC or A/B MAC (HHH) 
continues making rental payments until a total of 13 continuous rental months have been paid. The DME MAC 
  
  or A/B MAC (HHH) will not make any additional rental payments beyond the 13th rental month. On the first 
day after 13 continuous rental months have been paid, the supplier must transfer title to the equipment to the 
beneficiary. 
 
The rules also say that when no purchase options have been exercised, rental payments may not exceed a 
period of continuous use of longer than 15 months. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 20, Section 30.5.2. 
 
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. 
 
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 Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
You can find this rule in Local Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
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 tumor treatment field therapy is covered for the treatment of newly diagnosed Glioblastoma 
Multiforme (GBM) only when all of the following criteria are met: 
1. The beneficiary has histologically confirmed (World Health Organization (WHO) grade IV 
astrocytoma), newly diagnosed, supratentorial GBM; and, 
2. The beneficiary has received initial treatment with maximal debulking surgery (when feasible), 
followed by chemotherapy and radiotherapy; and, 
3. Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant 
chemotherapy or radiotherapy, whichever is later; and, 
4. The beneficiary has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) 
criteria; and, 
5. The beneficiary has a Karnofsky Performance Score (KPS) of at least 70; and, 
6. The beneficiary will use TTFT for an average of 18 hours per day. 
You can find these rules in the Local Coverage Determination (LCD) for Tumor Treatment Field Therapy 
(TTFT), L34823. 
 
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 PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
 
    Inclusion criteria (ALL are required): 
        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 
        Symptomatic (ONE): 
            Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 
8) 4-7 
            Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM)10 (ONE): 
                Worsening pain 
                Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    Progression of vertebral body height loss 
                    > 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17 
        Continuum of care10 (Both) 
            All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education 
for subsequent treatment as indicated. 
            All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
 
    Exclusion criteria 2,5,8-10 (Can have NONE of the following): 
        Absolute contraindication 
            Current back pain is not primarily due to the identified acute or subacute VCF(s). 
            Osteomyelitis, discitis or active systemic or surgical site infection 
            Pregnancy 
        Relative contraindication 
            Greater than three vertebral fractures per procedure 
            Allergy to bone cement or opacification agents 
            Uncorrected Coagulopathy 
            Spinal instability             Myelopathy from the fracture 
            Neurologic deficit 
            Neural impingement 
            Fracture retropulsion/canal compromise 
 
You can find this information in the Local Coverage Determination (LCD) Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) L34228. 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A53628. 
 
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 $275 copayment per day for days 1-5 and $0 per day for days 6-90 for 
in-network inpatient hospital care. You can find this information on pages 81-83 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. 
Molecular diagnostic tests used to assist in risk stratification of melanoma patients are covered when ALL of 
the following are true: 
1. The patient has a personal history of melanoma AND:  
1. Either:  
1. Has Stage T1b and above OR 
2. Has T1a with documented concern about adequacy of microstaging 
2. Is undergoing workup or being evaluated for treatment, AND 
3. Does not have metastatic disease AND 
4. Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, 
histological, or other information is greater than 5% AND 
5. Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the 
intended use of the test 
2. The TEST has demonstrated, as part of a Technical Assessment:  
1. Clinical validity of analytes tested in predicting metastatic disease (or the absence of metastatic 
disease) in peer-reviewed scientific literature 
2. Utility beyond clinical, histological, and radiographical factors in the ability to accurately 
stratify patients into risk groups to manage patient care, such by precluding unnecessary sentinel 
lymph node biopsies 
3. Appropriate analytical validity 
4. Performance characteristics equivalent or superior to other covered, similar tests 
You can find this rule in the Local Coverage Determination (LCD): MolDX: Melanoma Risk Stratification 
Molecular Testing (L37748). 
 
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 the condition code G0 specifies that multiple medical visits occurred on the same day with 
the same revenue center, and that these visits were distinct and constituted independent visits (e.g., two visits to 
the emergency room for chest pain, one in the morning and one in the afternoon, and/or two visits to the 
emergency room, one in the morning for a fractured arm and one later in the day for chest pain). 
You can find this rule in the Integrated OCE (IOCE) CMS Specifications V23.1 Effective April 1, 2022, titled 
Multiple Medical Visit Conditions, Section 5.1.2.1. 
 
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.