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 a $250 deductible which applies to certain items and services. The Plan 
deductible applies to a specialist visit. You can find this information in Chapter 4 on page 2 to 4 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 testing for the Fanconi anemia, complementation group C (FANCC) is not a Medicare 
benefit and is a statutorily excluded service. In addition to single gene testing,MolDX will also deny panels of 
tests that include the FANCC gene. You can find these rules in the Local Coverage Article Billing and Coding: 
MolDX: FANCC Genetic Testing, A53628. 
 
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/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). 
 
Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment under the OPPS is 
appropriate and the Secretary has determined that the services designated to be "inpatient only" services are not 
appropriate to be furnished in a hospital outpatient department. "Inpatient only" services are generally, but not 
always, surgical services that require inpatient care because of the nature of the procedure, the typical 
underlying physical condition of patients who require the service, or the need for at least 24 hours of 
postoperative recovery time or monitoring before the patient can be safely discharged. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Section 180.7. 
 
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/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 CPT codes for evaluation and management (E&M) services are principally included in the 
CPT code range 99202-99499. The codes describe the site of service (e.g., office, hospital, home, nursing 
facility, emergency department, critical care), the type of service (e.g., new or initial encounter, follow-up or 
subsequent encounter), and various miscellaneous services (e.g., prolonged physician service, care plan 
oversight service). Some E&M codes are based on the duration of the encounter (e.g., per diem services). A 
physician may report only one code from a range of codes describing an E&M service on a single date of 
service. A physician may report only one per diem E&M service from a range of per diem codes on a single 
date of service. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National 
Correct Coding Initiative Policy Manual, Chapter 11(U). 
 
The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. Instead of billing separately, the physicians 
should select a level of service representative of the combined visits and submit the appropriate code for that 
level. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.5. 
 
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. 
 
The rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when ALL of the following conditions are 
met: 
 
1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily 
living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 
2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space 
narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a 
diagnosis other than osteoarthritis of the knee). 
4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
 
a. Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, 
physical therapy if indicated); and 
b. If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product 
prescribing information. 
 
5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients symptoms and 
intra-articular corticosteroids are not contraindicated. 
 
You can find this rule in the Local Coverage Determination (LCD) - Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427) - Effective October 1, 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. 
 
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 says that your vision services - routine eyewear benefit includes 1 pair of standard lenses and frames 
every 2 years. You can find this information on page 4-56 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 state that genetic testing will be evaluated with the following parameters in mind: 
  
   
1. Is the test performed in the absence of clinical signs and symptoms of disease? 
2. Will the test results provide the clinician with information that will improve patient outcomes and/or 
change physician care and treatment of the patient? 
3. Will the test results confirm a diagnosis or known information? 
4. Is the test performed to determine risk for developing a disease or condition? 
5. Will risk assessment change management of the patient? 
6. Is there a diagnosis specific indication to perform the test? 
7. Is the test performed to measure the quality of a process or for Quality Control/Quality Assurance 
(QC/QA), i.e., a test to ensure a tissue specimen matches the patient? 
 
You can find more information in Local Coverage Determination (LCD): Psychiatry and Psychology Services 
(L33632). 
 
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/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 Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be 
used on claims for evaluation and management (E/M) services, and only when these services are provided by 
the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another 
procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global 
fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that 
is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not 
required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added 
to the E/M code on the claim. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.6. 
 
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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when both criteria are met: 
 
1. The patient has a personal history of melanoma AND: 
a. Either: 
i. Has Stage T1b and above OR 
ii. Has T1a with documented concern about adequacy of microstaging 
b. Is undergoing workup or being evaluated for treatment, AND 
c. Does not have metastatic disease AND 
d. Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, 
histological, or other information is >5% AND 
e. Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the 
intended use of the test 
2. The test has demonstrated, as part of a Technical Assessment: 
a. Clinical validity of analytes tested in predicting metastatic disease in peer-reviewed scientific 
literature 
b. Utility beyond clinical, histological, and radiographical factors in the ability to accurately 
stratify patients into risk groups to manage patient care 
c. Appropriate analytical validity 
d. Performance characteristics equivalent to other covered, similar tests 
 
You can find this rule in Local Coverage Determination (LCD): MolDX: Melanoma Risk Stratification 
Molecular Testing (L37748). 
 
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 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 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. In the absence of program instructions, Medicare contractors may determine the 
reasonable useful lifetime of equipment, but in no case can it be less than 5 years. Replacement due to wear is 
not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, 
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary 
equipment owned by the beneficiary.   You can find this information in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 
110.2. 
 
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules say that cardiovascular screening blood test means a lipid panel consisting of a total cholesterol, HDL 
cholesterol, and triglyceride. The test is performed after a 12-hour fasting period. Medicare Part B covers 
cardiovascular disease screening tests when ordered by the physician who is treating the beneficiary for the 
purpose of early detection of cardiovascular disease in individuals without apparent signs or symptoms of 
cardiovascular disease. Excluded from coverage are any services that are not reasonable and necessary, such as 
in the case of cardiovascular disease screening tests for the early detection of cardiovascular disease or 
abnormalities associated with an elevated risk for that disease, subject to the conditions specified in Section 
410.17 of this chapter. You can find this rule at 42 CFR, Sections 410.17 and 411.15. 
 
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 an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial 
branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) 
medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% 
sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
 
Repeat thermal11 facet joint RFA at the same anatomic site is considered medically reasonable and necessary 
provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months 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. 
 
Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L33930. 
 
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 a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for all other Medicare-covered prosthetic devices and 
supplies. You can find this information in Chapter 4 on page 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. 
 
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 the Plan covers Opioid Treatment Program Services. Members of our plan with opioid use 
disorder (OUD) can received coverage of services to treat OUD through an Opioid Treatment program (OTP) 
which includes the following services: U.S. Food and Drug Administration (FDA)-approved opioid agonist and 
antagonist medication-assisted treatment (MAT) medications. Dispensing and administration of MAT 
medications (if applicable). Substance use counseling, Individual and group therapy, Toxicology testing, Intake 
activities, Periodic assessments. You can find this information on page 86 of the Plans 2022 Evidence of 
Coverage. 
 
The Plan also covers outpatient mental health care. Covered services include mental health services provided 
by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, 
nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed 
under applicable state laws. The Plan covers outpatient substance abuse services. Covered services include 
diagnosis, establishment of a treatment plan, and follow-up care from a physician for substance abuse. You can 
find this information on page 91 of the Plan's 2022 Evidence of Coverage.