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 $340 copayment for in-network Medicare-covered outpatient hospital 
observation services.  You can find this information on page(s) 90 of the Plan's 2023 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 treatment for LUTS/BPH treatment will be considered reasonable and necessary when 
performed ONCE in patients with the following: 
Indications including ALL the following:  
1.  
a. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
b. Persistent moderate to severe symptoms despite maximal medical management 
including ALL the following: 
i. International Prostate Symptom Score (IPSS) 12 
ii. Maximum urinary flow rate (Qmax) of 15 mL/s (voided volume greater than 125 cc) 
iii. Failure, contraindication or intolerance to at least 3 months of conventional medical 
therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
Only treatment using a Food and Drug Administration (FDA) approved/cleared device will be considered 
reasonable and necessary. 
Limitations 
The following are considered not reasonable and necessary: 
1. Body mass index  42kg/m2 
2. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines) or a 
prostate specific antigen (PSA) >10 ng/mL unless the patient has had a negative prostate biopsy within 
the last 6 months 
3. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum 
4. Active urinary tract or systemic infection 
5. Treatment for chronic prostatitis 
6. Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 7. Damaged external urinary sphincter 
8. Known allergy to device materials 
9. Inability to safely stop anticoagulants or antiplatelet agents preoperatively 
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in 
this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and 
all existing CMS national coverage determinations (NCDs), and all Medicare payment rules. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L38549: Transurethral Waterjet 
Ablation of the Prostate. 
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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) 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 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that if the laboratory method is NGS testing, and the laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel, consistent with the 
NCCI manual Chapter 10, Section F, number 8. You can find this rule in the Local Coverage Article for the 
Billing and Coding of Molecular Pathology and Genetic Testing, A58917. 
 
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(s) 37-38 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 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 (CMS), Medicare National Correct Coding Initiative Policy 
Manual for Medicare Services, Chapter I(A). 
 
The rules say that all laboratory testing sites must have either a CLIA certificate of waiver, certificate for 
provider-performed microscopy procedures, certificate of registration, certificate of compliance, or certificate 
of accreditation to legally perform clinical laboratory testing on specimens from individuals in the United 
States. 
 
The Food and Drug Administration approves CLIA waived tests on a flow basis. The CMS identifies CLIA 
waived tests by providing an updated list of waived tests to the A/B MACs (A) and (B) on a quarterly basis via 
a Recurring Update Notification. To be recognized as a waived test, some CLIA waived tests have unique 
HCPCS procedure codes and some must have a QW modifier included with the HCPCS code. 
 
The CMS identifies the new HCPCS (non-waived, non-provider-performed procedure) codes, including any 
modifiers that are subject to CLIA edits by providing an updated listing of these tests to the A/B MACs (A) and 
(B) on an annual basis via a Recurring Update Notification. A facility that submits a claim for any test 
mentioned in the HCPCS codes that are subject to CLIA edits list must have either a valid, current CLIA 
certificate of registration (certificate type 9), a CLIA certificate of compliance (certificate type 1), or a CLIA 
certificate of accreditation (certificate type 3). 
 
 In addition, the CMS identifies the new HCPCS codes in the 80000 series that are excluded from CLIA edits 
by providing an updated listing of these tests to the A/B MACs (A) and (B) on an annual basis via a Recurring 
Update Notification. No CLIA certificate is required for a claim submitted for any test mentioned in the 
HCPCS codes in the 80000 series that are excluded from CLIA edits list. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 16, Sections 70.8 and 70.9. 
 
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 $10 copayment for in-network outpatient diagnostic tests.  You can find 
this information on page(s) 80-81 of the Plan's 2023 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 20% coinsurance for in-network prosthetic devices and related supplies.  
You can find this information on page(s) 107 of the Plan's 2023 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 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 
does not cover when solely provided by an independent acupuncturist. You can find this information on pages 
78 to 79 of the Plan's 2023 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(s) 47 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 $150 copayment for outpatient hospital services.  You can find this 
information on page(s) 44 of the Plan's 2023 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 20% coinsurance for in-network Medicare Part B drugs. You can find this 
information on pages 72-75 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $395 copayment for in-network outpatient surgery 
provided at an outpatient hospital. You can find this information on pages 86-88 of the Plans 2023 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 replacement of a prosthesis or prosthetic component is covered if the treating practitioner 
orders a replacement device or part because of any of the following: 
1. A change in the physiological condition of the beneficiary; or 
2. Irreparable wear of the device or a part of the device; or 
3. The condition of the device, or part of the device, requires repairs and the cost of such repairs would be 
more than 60% of the cost of a replacement device, or of the part being replaced. 
 
Replacement of a prosthesis or prosthetic components required because of loss or irreparable damage may be 
reimbursed without a practitioner's order when it is determined that the prosthesis as originally ordered still fills 
the beneficiary's medical needs. 
 
Protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers intended to be 
worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against 
unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the 
level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for cosmetic or 
convenience reasons, or for everyday usage in a typical environment. Protective outer surface coverings are 
different from the covering that is already reimbursed as part of L5704, L5705, L5706, and L5707. 
 
Foot covers are included in the codes for a prosthetic foot component and are not separately payable. You can 
find this rule in the Local Coverage Article for Lower Limb Prostheses, A52496. 
 
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 20% coinsurance for durable medical equipment and related supplies.  
You can find this information on page(s) 68 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 $25 copayment for outpatient rehabilitation services.  You can find this 
information on page(s) 80 of the Plan's 2023 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 $30 copayment for each specialist office visit. You can find this 
information on pages 79-81 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $50 copayment for outpatient diagnostic tests. You can 
find this information on pages 73-74 of the Plans 2023 EOC.