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 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules also state that services with status indicator N are paid under the Outpatient Prospective Payment 
System (OPPS), but their payment is packaged into payment for a separately paid service. This rule is found in 
the Medicare Claims Processing Manual, Chapter 4, Section 10.1.1 - Payment Status Indicators. 
 
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 in the case of tests for infectious agents, methodologies include detection by 
immunofluorescence, immunoassay, or nucleic acid probe techniques. A single laboratory procedure shall be 
reported as one unit of service whether it generates one or multiple results. When multiple procedures, multiple 
methodologies, or multiple kits are medically necessary and used to perform a test for multiple infectious 
agents, the units of service reported for codes that identify multiple infectious agents equals the number of 
different procedures, methodologies, or kits used to perform the test. You can find this information in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) 
Manual, Chapter 10, Section M(15). 
 
The rules say that the test panel is a single test with multiple components and is characterized by a single unit 
of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact 
that the test reports multiple individual pathogens and/or targets. You can find this rule in the Local Coverage 
Article for the Billing and Coding of Molecular Diagnostics (MolDX): Molecular Syndromic Panels for 
Infectious Disease Pathogen Identification Testing, A58710. 
 
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 & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 64 of the 2024 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 pharmacogenomics testing (PGx) testing is considered reasonable and necessary in limited 
circumstances as described below as an adjunctive personalized medical decision-making tool once a treating 
clinician has narrowed treatment possibilities to specific medications under consideration for use, or is already 
using a specified medication, based on other clinical considerations including the patients diagnosis, the 
patients other medical conditions, other medications, professional judgment, clinical science and basic science 
pertinent to the drug, and the patients preferences and values. 
PGx tests must demonstrate analytical validity, clinical validity, and clinical utility to be considered reasonable 
and necessary for coverage. This is demonstrated through a required technical assessment of the test. PGx tests 
are considered germline tests and must adhere to other relevant germline testing policies published by this 
contractor. You can find the rules in Local Coverage Determination (LCD) MolDX: Pharmacogenomics 
Testing L38394. 
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 in the case of tests for infectious agents, methodologies include detection by 
immunofluorescence, immunoassay, or nucleic acid probe techniques. A single laboratory procedure shall be 
reported as one unit of service whether it generates one or multiple results. When multiple procedures, multiple 
methodologies, or multiple kits are medically necessary and used to perform a test for multiple infectious 
agents, the units of service reported for codes that identify multiple infectious agents equals the number of 
different procedures, methodologies, or kits used to perform the test. You can find this information in the 
Centers for Medicare & Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) 
Manual, Chapter 10, Section M(15). 
 
The rules say that a panel of genes is a distinct procedural service from a series of individual genes. All 
services billed to Medicare must be medically reasonable and necessary. As such, if a provider or supplier 
submits a claim for a panel, then the patients medical record must reflect that the panel was medically 
reasonable and necessary. If the laboratory method is NGS testing, and the laboratory assays two or more genes 
in a patient in parallel, then those two or more genes will be considered part of the same panel. You can find 
this rule in the Local Coverage Article for the Billing and Coding of Molecular Pathology and Genetic Testing, 
A58917. 
 
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 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 & 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 in Chapter 3 on pages 40 to 41 of the Plan's 2024 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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
 
i. After the patient has had at least two medically reasonable and necessary diagnostic medial branch blocks 
(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) AND 
 
ii. Repeat thermal facet joint radiofrequency ablation (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 months or at least 50% consistent improvement in the ability to perform previously painful movements 
and activities of daily living (ADLs) as compared to baseline measurement using the same scale. 
  
You can find this information in Local Coverage Determination: Facet Joint Interventions for Pain 
Management (L38801). 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 1, Section 20.2. 
 
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, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. The Plan has a Point-of-Service (POS) option to cover certain 
out-of-network services. You will need to obtain authorization from the Plan prior to seeking care. You can 
find this information on pages 63-65 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 20% coinsurance for out-of-network covered services under 
the POS benefit. Authorization rules apply for out-of-network covered services. You can find this information 
on pages 197-202 of the Plans 2023 EOC.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens,
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other lifesaving
equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You
can find this rule at 42 CFR Section 410.41(a).

The rules say that plans may offer a supplemental benefit to provide transport not covered by original
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not
be used for other than health-related purposes. You can find this rule in the Centers for Medicare & Medicaid
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit
covers up to 24 one-way non-emergency transportation trips with a 50-mile limit per trip. You can find this
information on pages 79-80 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 $30 copayment for urgently needed services.  You can find this 
information on page(s) 107 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 20% coinsurance for Medicare-covered durable medical equipment. You 
can find this information on page 65 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 $375 copayment for in-network inpatient hospital care. The enrollee 
must pay a $375 copayment per day for days 1 to 5 for in-network inpatient hospital care. There is a $0 
copayment for days 6 to 90. You can find this information on page(s) 74-76 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 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 & Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
periapical first x-ray (D0220) but is limited to once every 3 years. The Plan contract also says there is a 20% 
coinsurance for endodontics, which includes a root canal on the molar (D3330). You can find this information 
on pages 56-60 of the Plan's 2023 Evidence of Coverage (EOC).