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 Non-invasive peripheral venous vascular studies utilize ultrasonic Doppler and physiologic 
studies to assess the irregularities in blood flow in the venous system. Noninvasive peripheral venous vascular 
studies include the patient care required to perform the studies, supervision of the studies, and interpretation of 
study results, with copies for patient records of test results and analysis of all data, including bi-directional 
vascular flow or imaging when provided. 
 
Diagnostic tests must be ordered by the physician who is treating the beneficiary and use the result in the 
management of the beneficiarys specific medical problem. Services are deemed medically necessary when all 
of the following conditions are met: 
 
   1. Signs/symptoms of ischemia or altered blood flow are present; 
   2. The information is necessary for appropriate medical and/or surgical management; 
   3. The test is not redundant of other diagnostic procedures that must be performed. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35751: Non-Invasive Peripheral 
Venous Vascular and Hemodialysis Access Studies. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
 
    1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the ICD-10 
code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over 
the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program 
including each of the following: 
        -Use of an appropriate group 1 support surface, and 
        -Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
        -Appropriate turning and positioning, and 
        -Appropriate wound care, and 
        -Appropriate management of moisture/incontinence, and 
        -Nutritional assessment and intervention consistent with the overall plan of care 
    2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis (refer to the ICD-
10 code list section in the LCD-related Policy Article for applicable diagnoses), 
    3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the 
past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing 
facility within the past 30 days. You can find this information in Local Coverage Determination (LCD): 
Pressure Reducing Support Surfaces - Group 2 (L33642). 
 
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 for chronic kidney disease patients not on dialysis 
1. Anemia of end stage renal disease (ESRD) with a hemoglobin (Hgb) less than 10 g/dL or a hemocrit 
(Hct) of less than 30% at initiation of therapy 
2. Serum creatinine equal to or greater than 3, creatinine clearance less than 60 ml/min, or glomerular 
filtration rate (GFR) less than 60 mL/min/1.73 m2 
You can find this information in Local Coverage Determination (LCD): Erythropoiesis Stimulating Agents 
(ESA) (L34356). 
 
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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 they do not cover other brands of monitors and test strips unless you or your provider 
requests a medical exception, and it is approved. You can find this information on pages 55-56 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 Medicare guidelines say that Percutaneous Left Atrial Appendage Closure (LAAC) is covered when all of 
these conditions are met: 
A greatly increased risk of stroke due to your abnormal heartbeats (atrial fibrillation)  
 Notes in your medical record that say a provider other than the doctor that is doing the heart procedure has 
talked to you about the positives and negatives of taking blood thinning medication and together you made a 
decision about what treatment is best for you (shared decision making)  
 Notes in your medical record say that the talk with your provider included the use of a tool called a medical 
calculator to tell you exactly what the risk of stroke versus the risk of bleeding would be for you taking blood 
thinners  
 You are able to take blood thinners for a short period after your heart procedure (around 6-7 weeks) but you 
are unable to take blood thinners on an ongoing basis  
 Notes in your medical record show you are or are going to be enrolled and taking part in a Medicare approved 
trial for this device. 
 
You can find this information in the National Coverage Determination (NCD) for Percutaneous Left Atrial 
Appendage Closure (LAAC) 
(20.34) 
 
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 ankle-foot orthoses represented by L1971 are covered for ambulatory beneficiaries with 
weakness or deformity of the foot and ankle, who: 
 
1. Require stabilization for medical reasons 
2. Have the potential to benefit functionally 
 
You can find this rule in the Local Coverage Determination (LCD) - Ankle-Foot/Knee-Ankle-Foot Orthosis 
(L33686) - Effective January 1, 2020. 
 
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 somatosensory evoked potentials and responses (SEPs/SERs) are appropriate for the 
following indications: 
 
1. Spinal cord trauma 
2. Degenerative, non-traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy) 
3. Multiple sclerosis 
4. Spinocerebellar degeneration 
5. Myoclonus 
6. Coma 
7. Intraoperative monitoring 
8. Subacute combined degeneration 
9. Other diseases of myelin (e.g., adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic 
leukodystrophy, and Pelizaeus-Merzbacher disease) 
10. Syringomyelia 
11. Hereditary spastic paraplegia 
 
You can find this rule in the Local Coverage Determination (LCD) - Neurophysiology Evoked Potentials 
(L34975) - Effective October 17, 2019. 
 
The rules say that SEP studies are appropriate only when a detailed clinical history and neurologic examination 
and appropriate diagnostic tests such as imaging studies, electromyogram, and nerve conduction studies make a 
lesion (or lesions) of the central somatosensory pathways a likely and reasonable differential diagnostic 
possibility. There is no need for SEPs in the diagnosis of most neuropathies because the conventional nerve 
conduction study can identify them and no added information is obtained from SEPs. You can find this rule in 
the Local Coverage Determination (LCD) - Neurophysiology Evoked Potentials (L34975) - Effective October 17, 2019. 
 
The rules say that below is a list of common disorders where an EMG, in tandem with properly conducted 
NCS, will be helpful in diagnosis: 
 
1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions 
2. Radiculopathy - cervical, lumbosacral 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies 
5. Plexopathy - idiopathic, trauma, infiltration 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here 
7. At times, immediately prior to Botulinum A toxin injection, for localization 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or 
chemodenervation 
 
There may be other instances, not detailed here, where EMG may be of use. You can find this rule in the Local 
Coverage Determination (LCD) - Nerve Conduction Studies and Electromyography (L35081) - Effective 
October 31, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the clinical use of contrast echocardiography (ECHO) is appropriate in selected patients to: 
- Evaluate myocardial ischemia  
- Quantify myocardial perfusion during stress  
- Identify the area at risk during acute myocardial infarction (AMI)  
- Determine the success of reperfusion interventions 
- Assess myocardial viability 
 
The plethora of structural and functional information provided by transthoracic echocardiogram (TTE) is 
unique among diagnostic testing modalities. The rapid and noninvasive acquisition of this information has 
contributed to exponential application, and to potential overutilization. 
 
Follow-up studies or limited studies may be covered. A complete study includes a full evaluation of all aspects 
of the heart, including the cardiac chambers, valves, blood flow, and great vessels. The images are reviewed, 
measured, analyzed and interpreted by the physician. A report is prepared for the patients record. You can find 
these rules in Local Coverage Determination (LCD) Echocardiography (L37379). 
 
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 Plan 
contract says that they have a link that will take you to a list of Part B Drugs that may be subject to Step 
Therapy. You can find this information in Chapter 4 on page 71 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. 
 
Transcutaneous Electrical Nerve Stimulator (TENS) therapy for Chronic Low Back Pain (CLBP) will be 
denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD): 
Transcutaneous Electrical Nerve Stimulators (TENS) (L33802). 
 
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 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 does not list a 
semi-precision attachment or diagnostic cast as a covered benefit. If a service is not listed, it is not covered. 
You can find this information on pages 58-60, and 106-126 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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 test strips and monitors must be obtained from preferred vendors. Test strips and 
monitors from any other vendor will not be covered. You can find this information on page 62 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. 
 
Continued coverage of a Positive Airway Pressure (PAP) device (E0470 or E0601) beyond the first three 
months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating 
therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is 
benefiting from PAP therapy. 
For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is 
demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
Adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights 
during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as 
not reasonable and necessary. 
You can find this rule in the Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices 
for the Treatment of Obstructive Sleep Apnea (L33718). 
 
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 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 Grievance Manual, Section 50.12.1. 
 
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 retainer 
crown porcelain fused to noble metal (D6752) and pontic-porcelain fused to noble metal (D6242). This benefit 
does not include abutment supported retainers for porcelain/ceramic fixed partial dentures (D6068). You can 
find this information on pages 61 to 63 of the Plans 2023 Evidence of Coverage (EOC).