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 stress testing without cardiac imaging will be considered medically reasonable and 
necessary for: 
 
    Patients with low or intermediate pre-test probability for CAD who are exhibiting cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms with normal or minor changes in resting ECG 
and no contraindications to exercise.5-10 
    Patients with diabetes mellitus who are exhibiting cardiac symptoms, including otherwise unexplained 
angina equivalent symptoms, with normal or minor changes in resting ECG and no contraindications to 
exercise.11 
    New-onset atrial fibrillation (with no prior cardiac evaluation).10,12,13 
    Determining functional capacity and response to therapy in patients with hypertrophic cardiomyopathy 
(HCM).14 
    Patients with an intermediate or high CHD risk (ATP III risk criteria) who have experienced syncope (an 
abrupt, transient, complete loss of consciousness) and cardiac etiology is suspected based on an initial 
evaluation, including history, physical examination, or ECG and the patient is able to exercise.6,8,10,15,16 
    Patients without cardiac symptoms who underwent a percutaneous coronary intervention (PCI) (with a stent) 
procedure more than 2 years prior or a coronary artery bypass graft (CABG) more than 5 years prior and have 
not undergone an evaluation for CAD within the past 2 years (stress echocardiogram, SPECT MPI, PET MPI, 
CMR, coronary computed tomography angiography [CCTA], cardiac catheterization) and are able to 
exercise.6,7,8,15,17,18 
    Patients with established CAD who experienced an acute coronary syndrome (ACS) event (ST segment 
elevation myocardial infarction [STEMI], a NonST segment elevation myocardial infarction [NSTEMI], or 
unstable angina) within the past 90 days provided that they did not undergo coronary angiography at the time 
of the acute event and are currently clinically stable and able to exercise.6,8 
    Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, 
peripheral vascular disease, carotid artery disease, chronic renal failure) with no stress testing evaluation 
performed within the preceding 2 years and who are able to exercise.5,7,10,17 
    Pre-operative cardiac evaluation in patients able to exercise and who will be undergoing noncardiac surgery 
with one of the following19: 
        Intermediate risk for surgery (cardiac risk 1-5%), unknown functional capacity, and the results will affect 
patient management decisions. 
        High risk for surgery (> 5% cardiac risk), unknown functional capacity, and the results will affect patient 
management decisions  
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. 
 
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 you have a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses 
or contact lenses. You pay any amount over $100 retail price. You can find this information on page 94 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 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 pages 101-103
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 copayment for medical eye exams. You can find this information on 
page 113 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 state that equipment which the beneficiary owns or is a capped rental item may be replaced in cases 
of loss or irreparable damage. The reasonable useful lifetime of durable medical equipment is determined 
through program  
instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful 
lifetime of equipment, but in no case can it be less than 5 years. This information is found in Medicare Benefit 
Policy Manual Chapter 15 - Covered Medical and Other Health Services 110 - Durable Medical Equipment - 
General, 110.2 - Repairs, Maintenance, Replacement, and Delivery. 
 
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 Initial Anti-Tumor Treatment Strategy Nationally Non-Covered Indications 
 
CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who 
have adenocarcinoma of the prostate. 
CMS continues to nationally non-cover FDG PET imaging for diagnosis of breast cancer and initial staging of 
axillary nodes. 
CMS continues to nationally non-cover FDG PET imaging for initial anti-tumor treatment strategy for the 
evaluation of regional lymph nodes in melanoma. 
CMS continues to nationally non-cover FDG PET imaging for the diagnosis of cervical cancer related to initial 
anti-tumor treatment strategy. 
 
You can find this information in the National Coverage Determination (NCD) Positron Emission Tomography 
(FDG) for Oncologic Conditions 220.6.17. 
 
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 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). 
 
Effective January 1, 2002, new modifiers were developed to allow practitioners and suppliers to bill Medicare 
for items and services that are statutorily non-covered or do not meet the definition of a Medicare benefit and 
items and services not considered reasonable and necessary by Medicare. 
 
1. Definitions of the GA, GY, and GZ Modifiers. The modifiers are defined below: 
 
GA - Waiver of liability statement on file. 
GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit. 
GZ - Item or service expected to be denied as not reasonable and necessary. 
 
The GZ modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect 
that Medicare will deny an item or service as not reasonable and necessary, and they have not had an Advance 
Beneficiary Notification (ABN) signed by the beneficiary. You can find this information in CMS Manual 
system, Pub 100-04 Medicare Claims Processing, Transmittal 2148, Change Request 7228. 
 
Effective for dates of service on and after July 1, 2011, A/B Medicare Administrative Contractors (MACs) 
shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs shall not perform 
complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make all 
language published in educational outreach materials, articles, and on their Web sites, consistent to state all 
claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. You can find this information in the CMS Internet only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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 $30 copayment for exams to diagnose and treat diseases and conditions 
of the eye by an Ophthalmologist (specialist). You can find this information on page 102 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the QS modifier is appended to monitored anesthesia care services. You can find this rule in 
the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 12, Section 50. 
 
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
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 280.3(B). 
 
The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which 
the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 
Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood).  A physician's order 
and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity 
of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific 
event cannot be identified.  Replacement of equipment due to irreparable wear takes into consideration the 
reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual, 
Chapter 15, Section 100.2. 
 
The rules say that the reasonable useful lifetime of durable medical equipment is determined through program 
instructions. In the absence of program instructions, A/B MACs may determine the reasonable useful lifetime 
of equipment, but in no case can it be less than five years. You can find this rule in the Medicare Benefit Policy 
Manual, Chapter 15, Section 100.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is needed for use in the home. 
Your home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a group 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 II pressure ulcers located on the trunk or pelvis 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: 
 
a. Use of an appropriate group 1 support surface 
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
c. Appropriate turning and positioning, and 
d. Appropriate wound care 
e. Appropriate management of moisture/incontinence, and 
f. Nutritional assessment and intervention consistent with the overall plan of care 
 
2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis 
 
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 rule in Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2 
(L33642) - 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 PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or for 
the treatment of chronic venous insufficiency with venous stasis ulcers. Reimbursement for these items is based 
upon the criteria in the following sections. PCD coded as E0675 is used in the treatment of peripheral arterial 
disease. A 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:  
 
-Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
-Papillomatosis cutis lymphostatica, 
-Deformity of elephantiasis, 
-Skin breakdown with persisting lymphorrhea, 
-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 rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
 
The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment is 
required. The four-week trial of conservative therapy must include all of the following: 
 
1. Regular and compliant use of an appropriate compression bandage system or compression garment to 
provide adequate graduated compression 
 -Adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid 
movement, and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid 
from distal to proximal. The compression used must not create a tourniquet effect at any point. 
-The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression 
starting with a minimum of 30 mmHg distally. 
 
2. Regular exercise 
3. Elevation of the limb 
 
You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - 
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.