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 for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 contract says that the Plan offers additional coverage for acupuncture beyond what is covered by Medicare. 
The Plan will pay for up to 12 visits in 90 days if you have chronic low back pain. The Plan will pay for an 
additional 8 sessions if you show improvement. The Plan also covers acupuncture in addition to the Medicare 
covered services. This benefit covers up to 36 visits total per calendar year unless authorized differently in your 
individualized care plan. The 36 sessions are not in addition to the 20 covered session above if it is for lower 
back pain. It is a total of 36 sessions between both Medicare and the Plan's coverage if medically necessary. 
You can find this information on page 49 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. 
Effective for services performed on or after March 16, 2018, the Centers for Medicare & Medicaid Services 
(CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable 
and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have:  
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; 
and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to 
specify treatment options. 
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 90.2. 
 
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). 
 
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 disposable drug delivery systems, including elastomeric infusion pumps are non-covered 
devices because they do not meet the Medicare definition of durable medical equipment. Drugs and supplies 
used with disposable drug delivery systems are also non-covered items. You can find this information in Local 
Coverage Article (LCA): External Infusion Pump - Policy Article (A52507). 
 
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 indications for venous surgical treatment  for example venous ligation, vein stripping, 
and/or sclerotherapy, are: 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, 
compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, and 
2. The patient is symptomatic and has one, or more, of the following: 
a. Pain or burning in the extremity severe enough to impair mobility 
b. Recurrent episodes of superficial phlebitis 
c. Non-healing skin ulceration 
d. Bleeding from a varicosity 
e. Stasis dermatitis 
f. Refractory dependent edema 
 
In addition to the above, as indications for endovenous radiofrequency ablation (ERFA) or laser ablation the 
patient's anatomy and clinical condition are amenable to the proposed treatment including all of the following: 
1. Absence of aneurysm in the target segment. 
2. Maximum vein diameter of 12 millimeters for ERFA or 20 millimeters for laser ablation 
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. 4. The absence 
of significant peripheral arterial diseases. 
 
The limitations for ERFA and laser ablation are: 
1. ERFA and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or 
greater saphenous veins and their tributaries which have failed 3 months of conservative therapy. 
2. Intra-operative ultrasound guidance is not separately payable with ERFA, laser ablation, and 
sclerotherapy. 
3. The treatment of asymptomatic varicose veins, or symptomatic varicose veins without a 3-month trial of 
conservative measures, by any technique will be considered cosmetic and therefore not covered. 
4. The treatment of spider veins or superficial telangiectasis by any technique is considered cosmetic, and 
therefore not covered. 
5. Coverage is only for devices specifically Food & Drug Administration (FDA)-approved for these 
procedures. 
6. One pre-operative Doppler ultrasound study or duplex scan will be covered. 
 You can find these rules in Local Coverage Determination (LCD) Treatment of Varicose Veins of the Lower 
Extremities (L34010). 
 
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 an initial thermal radiofrequency ablation (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 thermal 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. One to two levels, 
either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level 
procedure bilaterally may be considered under unique circumstances and with sufficient documentation of 
medical necessity on appeal. You can find this rule in the Local Coverage Determination for Facet Joint 
Interventions for Pain Management, L33930. 
 
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 a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17). 
 
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 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 (6) months or at least 50% consistent improvement in the ability to perform 
previously painful movements and activities of daily living as compared to baseline measurement using the 
same scale. You can find this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L35936). 
 
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. 
 
Clinical laboratory diagnostic tests can include tests that, for example, predict the risk associated with one or 
more genetic variations. Next Generation Sequencing (NGS) is one technique that can measure one or more 
genetic variations as a laboratory diagnostic test, such as when used as a companion in vitro diagnostic test. 
 
Effective for services performed on or after January 27, 2020, NGS is considered a diagnostic laboratory test 
that is reasonable and necessary and covered nationally for patients with germline (inherited) cancer, when 
performed in a certified laboratory, when ordered by a treating physician and when all of the following 
requirements are met: 
 
a. Patient has: 
i. ovarian or breast cancer; and, 
ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and, 
iii. a risk factor for germline (inherited) breast or ovarian cancer; and 
iv. not been previously tested with the same germline test using NGS for the same germline genetic content. 
 
 You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual, Next Generation Sequencing (NGS) 
NCD 90.2. 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 Plan 
contract says that services from either network or out-of-network providers are covered, as long as the services 
are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share 
of the costs for your covered services may be higher. You can find this information on pages 46 to 47 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 the following devices are listed under the Food and Drug Administration (FDA) approval 
documents as electro-acupuncture devices used for stimulation of auricular acupuncture points and as such are 
non-covered. Acupuncture for stimulation of auricular points is not a covered Medicare benefit. 
 NeuroStim system/NSS 
 P-Stim 
 ANSiStim 
 E-Pulse 
You can find this rule in Local Coverage Article Billing and Coding Billing and Coding: Auricular Peripheral 
Nerve Stimulation (Electro-Acupuncture Device) A55240. 
 
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 $295 copay per one-way trip for domestic ambulance services. You can 
find this information on page 68 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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. 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 220.1(A). 
 
The rules say that the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
1. stress fracture. 
2. spondylosis. 
3. infection (e.g., discitis). 
4. tumor (e.g., osteoid osteoma). 
5. analyze blood flow to an organ, as in the case of myocardial viability. 
6. differentiate ischemic heart disease from dilated cardiomyopathy. 
 
You can find this rule in the National Coverage Determination (NCD) - Single Photon Emission Computed 
Tomography (SPECT) - Effective October 1, 2002. 
 
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 while the Medicare program generally excludes routine foot care services from coverage, 
there are specific indications or exceptions under which there are program benefits. Medicare payment may be 
made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral 
vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put 
the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or 
areas of desensitization in the patients legs or feet). Treatment of mycotic nails may be covered under the 
exceptions to the routine foot care exclusion. The class findings, or the presence of qualifying systemic 
illnesses causing a peripheral neuropathy, must be present. You can find this rule in the Local Coverage 
Determination and Article for Routine Foot Care and Debridement of Nails, L33636 and A57759. 
 
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 a power wheelchair is covered if the beneficiarys home provides adequate access between 
rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided. 
You can find this rule in the Local Coverage Determination (LCD), L33789. 
 
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.