Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that pharmacogenetics testing will be considered medically reasonable and necessary if: 
-The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
-The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA label. 
 
You can find this information in Local Coverage Determination (LCD): Pharmacogenomics Testing (L39073). 
 
Genetic testing for hereditary cardiovascular disease will be considered medically reasonable and necessary if: 
 
    -The patient has rigorous disease-appropriate phenotyping to establish clinical diagnosis or suspected 
diagnosis for which the test results would directly impact the management of the patients condition, prior to 
ordering the test AND 
    -The evidence for the gene-disease association is evaluated by the evidence-based, transparent, peer-
reviewed process of the National Institutes of Health (NIH) sponsored Clinical Genome Resource (ClinGen) 
and is determined to demonstrate actionability in clinical decision making, meeting all bulleted metrics: 
        -Disease severity of sudden death, possible death or major morbidity, modest morbidity 
        -Substantial or moderate evidence of a >40% likelihood of disease 
        -Substantial or moderate evidence of a highly effective or moderately effective intervention 
        -The nature of intervention is either low risk/medically acceptable/low intensity intervention or 
moderately acceptable/risk/intensive interventions, AND     -Clinical validity and qualitative descriptors from Moderate, Strong & Definitive with contradictory 
evidence NOT being reported as disputed or refuted. 
 
You can find this information in Local Coverage Determination (LCD): Genetic Testing for Cardiovascular 
Disease (L39084). 
 
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 pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the 
following three requirements are met: 
1. The beneficiary has a diagnosis of lymphedema as defined above, and 
2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings:  
o Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
o Papillomatosis cutis lymphostatica, 
o Deformity of elephantiasis, 
o Skin breakdown with persisting lymphorrhea, 
o Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to 
other clinical treatment over the course of a required four-week trial.  
You can find this information in the Local Coverage Determination (LCD) for 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 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 $15 copayment for physician/practitioner services, including doctors 
office visits. You can find this information on page(s) 96 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 Original Medicare pays for the routine costs of qualifying clinical trials. Medicare also pays 
for reasonable and necessary items and services used to diagnose and treat complications arising from 
participation in all clinical trials. The rules also say that Medicare plans must cover these services even if they 
are not available through in-network providers. Medicare plans may require reporting when enrollees 
participate in clinical trials but cannot require prior authorization or approval. You can find these rules in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National 
Coverage Determinations Manual, Chapter 1, Section 310.1.  
 
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. The Plan 
contract also says that a clinical research study or clinical trial is a way that doctors and scientists test new 
types of medical care. They test new medical care procedures or drugs by asking for volunteers to help with the 
study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a 
new approach works and if it is safe. 
 
An enrollee who is in a clinical research study may stay enrolled in the Plan and continue to get the care that is 
not related to the study through the Plan. Enrollees must tell the plan before they start participating in a clinical 
research study. 
 
If an enrollee participates in a Medicare-approved study, Original Medicare pays most of the costs for the 
covered services received as part of the study. After Medicare has paid its share of the cost for these services, 
the Plan will also pay for part of the costs. The Plan will pay the difference between the cost-sharing in 
Original Medicare and the cost-sharing as a member of the Plan. This means the enrollee will pay the same 
amount for the services received as part of the study as he or she would if these services were received from the 
Plan. You can find this information on pages on page 38 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 will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
  
  defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 certain dental services as a supplemental (extra) benefit. This benefit includes only the 
items and services listed in the dental services benefit category. Intravenous sedation (D9239, D9243) may be 
covered by the Plan's dental benefits. Prior authorization may be required. You can find this information on 
pages 63-67 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 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 $100 copayment for Medicare-covered ultrasounds. You can find this 
information on page(s) 92 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% coinsurance for each Medicare-covered outpatient surgery at an 
outpatient facility. You can find this information on pages 109 to 112 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 $0 copayment for physician/practitioner services, including doctors 
office visits. You can find this information on page 90 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 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 physician/practitioner services, including doctors 
office visits. You can find this information on page(s) 75 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 $300 copayment per day for days 1-6 of each in-network inpatient 
hospital stay. Enrollees then pay a $0 copayment per day for days 7-90 of each in-network inpatient hospital 
stay. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The 
day before you are discharged is your last inpatient day. You can find this information on pages 51-52 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that elastic stockings are not covered because they are non-reusable supply items. Elastic 
stockings are not durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, 
Chapter 1, Section 280.1.   
  
The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5.  
 
The rules also say that compression bandages, multi-layer systems, and gradient compression wraps are 
covered only when they are used as dressings over a qualifying wound. A qualifying wound is either a wound 
caused or treated by surgery or a wound that must be debrided. A gradient compression stocking or wrap 
described by codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open 
venous stasis ulcer. Gradient compression stockings and wraps identified with codes A6531, A6532, and 
A6545 are not covered when they are used to treat the following conditions: 
 
Venous insufficiency without stasis ulcers; 
Prevention of stasis ulcers; 
Prevention of the reoccurrence of stasis ulcers that have healed; 
Treatment of lymphedema in the absence of ulcers. 
 You can find these rules in Local Coverage Determination (LCD): Surgical Dressings L33831 and Local 
Coverage Article: Surgical Dressings-Policy Article A54563, effective for services performed on or after July 
24, 2017. 
 
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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d)  
    continuing occupational therapy.  
 
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
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. 
 
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 virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are not 
covered out-of-network. You can find this information on page 117 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 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 Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says you are covered by both Medicare and Medicaid. Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (kidney failure). Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies depending on the state and the type of Medicaid you have. Some people with Medicaid get help paying for their Medicare premiums and other costs. Other people also get coverage for additional services and drugs that are not covered by Medicare. You can see this on page 11 of the Plans 2022 Evidence of Coverage.
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 20% coinsurance for Medicare Part B prescription drugs. You can find this information on page 71 of the Plan's 2022 Evidence of Coverage (EOC).