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 this coverage policy provides the following information: 
 
    defines tests required to register for a unique identifier 
    defines tests required to submit a complete technical assessment (TA) for coverage determination 
    defines the payment rules applied to covered tests that are not reported with specific codes from a code set 
recognized in 45 CFR 162.1002 (a)(5), and termed HIPAA compliant code sets throughout the remainder of 
this LCD 
    lists specific covered tests that have completed the registration and TA process and meet Medicares 
reasonable and necessary criteria for coverage 
 
Tests evaluated through the application process and/or technical assessment will be reviewed to answer the 
following questions: 
 
    Is the test performed in the absence of clinical signs and symptoms of disease? 
    Will the test results provide the clinician with information that will improve patient outcomes and/or change 
physician care and treatment of the patient? 
    Will the test results confirm a diagnosis or known information? 
    Is the test performed to determine risk for developing a disease or condition? 
    Will risk assessment change management of the patient? 
    Is there a diagnosis specific indication to perform the test? 
    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 this information in the Local Coverage Determination (LCD) MolDX: Molecular Diagnostic 
Tests (MDT) L35025. 
 
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 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, 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. You can find this information in Chapter 3 on page 37 of the 
Plan's 2022 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 $275 copayment for outpatient hospital observation. You can find this 
information on page(s) 100 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 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. 
 
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 when the enrollee is outside of the Plan's service area and cannot get care from a network 
provider, the Plan will cover urgently needed services obtained from any provider. You can find this 
information in Chapter 3 on pages 47 to 48 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 PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
 
    Inclusion criteria (ALL are required): 
        Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) based on symptom onset, and 
documented by advanced imaging  (bone marrow edema on MRI or bone-scan/SPECT/CT uptake) 1-
3,10,25,27 
        Symptomatic (ONE): 
            Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 
8) 4-7 
            Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM)10 (ONE): 
                Worsening pain 
                Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                    Progression of vertebral body height loss 
                    > 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17 
        Continuum of care10 (Both) 
            All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education 
for subsequent treatment as indicated.  
            All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program.  
 
    Exclusion criteria 2,5,8-10 (Can have NONE of the following): 
        Absolute contraindication 
            Current back pain is not primarily due to the identified acute or subacute VCF(s). 
            Osteomyelitis, discitis or active systemic or surgical site infection 
            Pregnancy 
        Relative contraindication 
            Greater than three vertebral fractures per procedure 
            Allergy to bone cement or opacification agents 
            Uncorrected Coagulopathy             Spinal instability 
            Myelopathy from the fracture 
            Neurologic deficit 
            Neural impingement 
            Fracture retropulsion/canal compromise 
 
You can find this information in the Local Coverage Determination (LCD)Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) L34106. 
 
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 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 life-
saving 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 
doctors 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 and 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 ten one-way trips to plan-approved locations every year. You can find this information on pages 
61 to 62 of the Plans 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 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 $90 copayment for emergency care. You can find this information on 
page 76 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 High frequency chest wall oscillation devices (HFCWO) (E0483) are covered for 
beneficiaries who meet: 
 
    Criterion 1, 2, or 3, and 
 
    Criterion 4 
 
    1. There is a diagnosis of cystic fibrosis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses). 
 
    2. There is a diagnosis of bronchiectasis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses) which has been confirmed by a high resolution, spiral, or standard CT scan and which is 
characterized by: 
 
                Daily productive cough for at least 6 continuous months; or 
 
                Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. 
 
                Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed   
diagnosis of bronchiectasis do not meet this criterion. 
 
   3. The beneficiary has one of the following neuromuscular disease diagnoses (refer to the ICD-10 code list in 
the LCD-related Policy Article for applicable diagnoses): 
        Post-polio 
        Acid maltase deficiency 
        Anterior horn cell diseases 
        Multiple sclerosis 
        Quadriplegia 
        Hereditary muscular dystrophy 
        Myotonic disorders 
        Other myopathies 
        Paralysis of the diaphragm 
    4. There must be well-documented failure of standard treatments to adequately mobilize retained secretions. 
 
If all of the criteria are not met, the claim will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) High Frequency Chest Wall 
Oscillation Devices L33785. 
 
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 $10 copayment for in-network physician/practitioner services/primary 
care provider visit. You can find this information on pages 114-118 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 continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy 
requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating 
practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP 
therapy. 
 
For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is 
demonstrated by: 
 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
Adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights 
during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as 
not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea L33718. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that continued coverage of a positive airway pressure (PAP) device (E0470 or E0601) beyond 
the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after 
initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the 
beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after November 
1, 2008, documentation of clinical benefit is demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of 
obstructive sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
Adherence to therapy is defined as use of PAP 4 or more hours per night on 70% of nights during a consecutive 
thirty (30) day period anytime during the first three (3) months of initial usage. If the above criteria are not met, 
continued coverage of a PAP device and related accessories will be denied as not reasonable and necessary. 
You can find these rules in Local Coverage Determination (LCD) Positive Airway Pressure (PAP) Devices for 
the Treatment of Obstructive Sleep Apnea (L33718). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Lynch Syndrome (LS) tumor screening for DNA mismatch repair (MLH1, MSH2, MSH6 and PMS2) by 
qualitative IHC and/or microsatellite instability (MSI) is considered medically necessary and covered by 
Medicare for the following indications:  
 All individuals with colorectal cancer diagnosed at age less than or equal to 70 years of age, and those 
greater than 70 years of age who meet the revised Bethesda guidelines OR 
 Individuals with endometrial cancer 
No definitive algorithm for LS screening has been recommended. However, if IHC is done first and is 
abnormal, MSI testing is not warranted. If IHC is normal, MSI may be warranted. IHC testing LS is qualitative 
and does not require the use of tumor morphometry.  
You can find this information in the Local Coverage Determination (LCD): Special Histochemical Stains and 
Immunohistochemical Stains (L36353). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says to visit the provided link for a complete list of dental procedures. You can find this information 
on page 74 of the Plan's 2022 Evidence of Coverage. 
 
The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan 
contract says name brand, laboratory processed or in-office processed crowns/pontics produced through 
specialized technique or materials are material upgrades. The Contract Dentist may charge an additional fee not 
to exceed $325.00 in addition to the listed copayment. The contract also says that you are responsible for a 
$425 copayment for crowns (D2750). You can find this information on pages 2 and 3 of the Plans 2022 
Schedule A, Description of Benefits and Copayments.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes only the 
items and services listed in the mandatory supplemental dental benefits chart. A limited oral evaluation 
(D0140) and core build up (D2950) are not covered by the Plan's supplemental dental benefits. You can find 
this information on pages 91-93 of the Plans 2022 Evidence of Coverage (EOC).