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).  
 
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 there is $150 deductible which applies to certain items and services. The Plan deductible 
applies to most of your covered services. You can find this information on page 47 of the Plan's 2023 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 10 one-way trips to plan approved locations every year. You can find this information on pages 55 
to 56 of the Plans 2023 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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(A). 
 
The rules say that a cardiac computed tomography (CCT) scan may be covered for these indications: 
 
a. Patient presenting with chest pain syndrome. 
b. To facilitate the management decision of a patient with an equivocal stress test. 
c. When the recurrence of symptoms in patients with known coronary artery disease may be related to 
progression/exacerbation of underlying disease. 
d. When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or 
dyspnea. 
e. Suspected congenital anomalies of the coronary circulation. 
f. The assessment of coronary or pulmonary venous anatomy. 
g. The patient undergoing non-coronary artery cardiac surgery. 
h. The test may be medically necessary in patients presenting to the emergency room with complaints 
consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes. 
i. The test may be considered medically necessary in patients status post revascularization procedures who 
present with recurrent symptoms not clearly identifiable as ischemic. 
 
You can find this information in the Local Coverage Determination (LCD) L33559: Cardiac Computed 
Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA). 
 
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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(A). 
 
The rules say that a cardiac computed tomography angiography (CCTA) scan may be covered for these 
indications: 
 
a. Patient presenting with chest pain syndrome. 
b. To facilitate the management decision of a patient with an equivocal stress test. 
c. When the recurrence of symptoms in patients with known coronary artery disease may be related to 
progression/exacerbation of underlying disease. 
d. When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or 
dyspnea. 
e. Suspected congenital anomalies of the coronary circulation. 
f. The assessment of coronary or pulmonary venous anatomy. 
g. The patient undergoing non-coronary artery cardiac surgery. 
h. The test may be medically necessary in patients presenting to the emergency room with complaints 
consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes. 
i. The test may be considered medically necessary in patients status post revascularization procedures who 
present with recurrent symptoms not clearly identifiable as ischemic. 
 
You can find this information in the Local Coverage Determination (LCD) L33559: Cardiac Computed 
Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA). 
 
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 must report services correctly. Procedures should be reported with the Current 
Procedural Terminology (CPT) code that describes the services performed. The rules also say that modifiers 
may be appended to Healthcare Common Procedure Coding System (HCPCS)/CPT codes only if the clinical 
circumstances justify the use of the modifier. A modifier shall not be appended to a HCPCS/CPT code solely to 
bypass a National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit if the clinical 
circumstances do not justify its use. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I. 
 
The rules say that the CPT Manual defines modifier 25 as a significant, separately identifiable evaluation and 
management service by the same physician or other qualified health care professional on the same day of the 
procedure or other service. Modifier 25 may be appended to an evaluation and management (E&M) CPT code 
to indicate that the E&M service is significant and separately identifiable from other services reported on the 
same date of service. The E&M service may be related to the same or different diagnosis as the other 
procedure(s). You can find this information in the CPT Coding Manual. 
 
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 100 of the 2023 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 medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) 
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an 
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at 
the discretion of Medicare. 
 
The rules say that Medicare will cover a PET scan for enrollees who have cancers that are biopsy proven or 
strongly suspected based on other diagnostic testing when the beneficiarys treating physician determines that 
the FDG PET study is needed to determine the location and/or extent of the tumor for the following therapeutic 
purposes related to the initial treatment strategy: 
 To determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or    
   therapeutic procedure; or  
 To determine the optimal anatomic location for an invasive procedure; or  
 To determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends  
   on the extent of the tumor. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, National Coverage Determinations Manual, Section 220.6.17. 
 
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, effective December 1, 2000, Medicare covers sodium ferric gluconate complex in sucrose 
injection as a first line treatment of iron deficiency anemia when furnished intravenously to patients undergoing 
chronic hemodialysis who are receiving supplemental erythropoeitin therapy. 
 
Effective October 1, 2001, Medicare also covers iron sucrose injection as a first line treatment of iron 
deficiency anemia when furnished intravenously to patients undergoing chronic hemodialysis who are 
receiving supplemental erythropoeitin therapy. You can find this rule in the Center for Medicare and Medicaid 
Services (CMS) Internet-Only Manual, Publication 100-03, Medicare National Coverage Determination (NCD) 
Manual, Section 110.10. 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet ALL the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet 
ALL the following criteria: 
        a. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with 
each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used); AND 
       b. Subsequent therapeutic facet joint procedures at the same anatomic site results in at least consistent 
50% pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent 
improvement in the ability to perform previously painful movements and ADLs as compared to baseline 
measurement using the same scale; AND 
      c. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established 
spinal pseudarthrosis, implanted electrical device) 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35936: Facet Joint Interventions 
for Pain Management. 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 patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise 
unexplained angina equivalent symptoms, AND any of the following: 
 
    Physical inability to perform a maximum exercise workload2,5,6,8-10,15,20; OR 
 
    New or previously unrecognized uninterpretable ECG2,5,6,8-10 OR; 
 
                ECG is uninterpretable for ischemia due to any one of the following2,5,8,9,15,21: 
 
                    Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for 
ischemia),21 
 
                    Ventricular paced rhythm, 
 
                    Pre-excitation pattern such as Wolff-Parkinson-White, 
 
                    A > 1 mm ST segment depression (NOT nonspecific ST/T wave changes), 
 
                    Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH with strain 
(NOT without repolarization abnormalities or by voltage criteria), or 
 
                    Patient on digoxin therapy. 
 
You can find this information in the Local Coverage Determination (LCD) Cardiology Non-emergent 
Outpatient Stress Testing L35083. 
 
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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 48 one-way non-emergency transportation trips via contracted transportation providers to plan-approved 
locations to receive health care services from network providers. You can find this information on page 83 of 
the Plans 2023 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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 24 one-way rides per year to other health care related locations (such as to the pharmacy or 
specialist appointments).  You can find this information on page 86 of the Plans 2023 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 both a nerve conduction velocity study and an electromyogram must be performed 
involving the nerve(s) being studied on the same date of service in order to be reimbursed for those procedures. 
The only exception is in the diagnosis of carpal tunnel which may not in all cases require both a nerve 
conduction velocity study and an electromyogram. You can find this rule at the Medicare Local Coverage 
Article (LCA) A56619: Billing and Coding: Nerve Conduction Studies and Electromyography. 
 
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.