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 Noninvasive testing in the outpatient setting to assess for coronary artery disease (CAD) and 
left ventricular (LV) dysfunction may be accomplished by utilizing conventional exercise stress testing without 
imaging or by utilizing exercise or pharmacologic stress testing with imaging. 
 
Cardiovascular stress testing, also referred to as exercise stress test (EST), exercise electrocardiogram, exercise 
treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information 
about how the heart responds to exertion. 
 
Types of stress testing with imaging addressed in this LCD include stress echocardiography, single photon 
emission computed tomography (SPECT) myocardial perfusion imaging (MPI), positron emission tomography 
(PET) MPI, and cardiac magnetic resonance imaging (CMR). Stress testing with imaging can be performed 
with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine, regadenoson, or other 
provocative agents). 
 
Stress echocardiography, SPECT MPI, PET MPI and CMR are considered equivalent diagnostic tests. 
However, in addition to myocardial ischemia, stress echocardiography can provide information that is not 
obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic 
obstruction. The most commonly performed myocardial perfusion imaging are single (at rest or stress) and 
multiple (at rest and stress) SPECT studies. The CMR can also distinguish scar from hibernating myocardium, 
provide information about valvular function, the presence of myocardial fibrosis, the presence of 
morphological abnormalities, and provide an assessment of dynamic obstruction without radiation exposure. 
This is especially valuable in patients in whom good quality echocardiography images could not be obtained 
due to technically difficult acoustic windows. You can find these rules in the Local Coverage Determination 
(LCD) Cardiology Non-emergent Outpatient Stress Testing L35083. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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 rules say that one treatment for lower urinary tract symptoms attributable to benign prostatic 
hyperplasia (LUTS/BPH) treatment is covered once in patients with both the following:  
1. Indications including all of the following:   
a. Age 50 or greater 
b. Symptomatic despite maximal medical management including all of the following:  
i. International Prostate Symptom Score (IPSS) of 13 or greater 
ii. Maximum urinary flow rate (Qmax) of 15 milliliters per second or less (voided volume 
greater than 125 cubic centimeters (cc)) 
iii. Failure, contraindication or intolerance to at least three months of conventional medical 
therapy for BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
c. Prostate volume of 30-80 cc, 
d. Poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac 
disease, pulmonary disease, etc.), or at high risk of bleeding  
2. No contraindications including all of the following:  
a. Known or suspected prostate cancer (based on National Comprehensive Cancer Network 
(NCCN) Prostate Cancer Early Detection guidelines) or a prostate specific antigen (PSA) of 10 
nanograms per milliliter or greater 
b. Active urinary tract infection  
c. History of bacterial prostatitis in the past three months  
d. Prior prostate surgery  
e. Neurogenic bladder  
f. Active urethral stricture (i.e., the source of the current LUTS) 
You can find these rules in Local Coverage Determination (LCD) Water Vapor Thermal Therapy for 
LUTS/BPH (L37808). 
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 Medicare covers fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scans 
for either the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimers disease (AD) under 
specific requirements; OR, its use in a Centers for Medicare & Medicaid Services (CMS)-approved practical 
clinical trial focused on the utility of FDG PET in the diagnosis or treatment of dementing neurodegenerative 
diseases. 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: FDG PET for Dementia and 
Neurodegenerative Diseases (220.6.13). 
 
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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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. 
  
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 142 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 126 of the Plans 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(a) and in 
the Centers for Medicare and 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. You can find this information on page(s) 3-7 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 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 $325 copayment for Outpatient surgery in an ambulatory surgical 
center. You can find this information on page(s) 96 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 a group 3 power wheelchair with a single power option will be covered if the beneficiary's 
mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and either 
the beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options and 
Accessories policy) and the system is being used on the wheelchair or the beneficiary requires a drive control 
interface other than a hand or chin-operated standard proportional joystick. You can find these rules in Local 
Coverage Determination (LCD):Power Mobility Devices (L33789). 
 
A power seating system  tilt only, recline only, or combination tilt and recline  with or without power 
elevating legrests will be covered if 
 
    The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
 
    The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed; or 
 
    The power seating system is needed to manage increased tone or spasticity. 
 
You can find these rules in Local Coverage Determination (LCD):Wheelchair Options/Accessories (L33792). 
 
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 and 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. You can find this information on page(s) 40 to 55 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 computed tomography cerebral perfusion analysis (CTP) (using automated post-processing 
software algorithmic analysis) is medically reasonable and necessary in patients with acute ischemic stroke 
(AIS) caused by unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke 
centers; CTP can be used to aid in selection for endovascular mechanical thrombectomy (EVT) if one of the 
following other conditions is fulfilled: 
 
1. Treatment (femoral puncture) can be started within 6-24 hours of the time last known to be at neurologic 
baseline and who meet the pre-CTP inclusion/exclusion criteria as defined by the DAWN trial, or 
2. Treatment (femoral puncture) can be started within 6-16 hours of the time last known to be at neurologic 
baseline and who meet the pre-CTP inclusion/exclusion criteria as defined by the DEFUSE 3 trial 
 
*excluding criteria purely related to study mechanics (e.g., able to return for protocol required follow-up visits, 
etc.) 
 
You can find this rule in the Local Coverage Determination (LCD) - Computed Tomography Cerebral 
Perfusion Analysis (CTP) (L38700) - Effective December 13, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $35 copayment for each covered specialist office visit under Physician 
or Practitioner Services. You can find this information on page 98 of the Plan's 2021 Evidence of Coverage 
(EOC).  
 
The Plan contract says enrollees must pay a $40 copayment for each covered specialist visit under Physician or 
Practitioner Services. You can find this information on page 86 of the Plans 2020 Evidence of Coverage. 
 
The Plan contract says that enrollees must pay a $10 copayment for each covered laboratory service under 
Outpatient Diagnostic Tests and Therapeutic Visits and Supplies. You can find this information on page 91 of 
the Plans 2021 Evidence of Coverage and page 80 of the Plans 2020 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 a $25 copayment for physician/practitioner services, including doctors 
office visits. You can find this information on page(s) 87 to 88 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 code E2311 describes an electronic component that allows the patient to control two or more 
of the following motors from a single interface; e.g. proportional joystick, touchpad or nonproportional 
interface: 
 
-Power tilt 
-Power recline, with or without shear reduction 
-Combination power tilt and recline, with or without shear reduction 
-Power leg elevation with or without articulation, power center mount elevating foot platform with or without 
articulating properties 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 $290 copayment for Outpatient Hospital Services. You can find this 
information on page 104 of the Plan's 2022 Evidence of Coverage (EOC).