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 if a laboratory procedure produces multiple reportable test results, only a single 
HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the 
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. 
This rule is found in National Correct Coding Initiative Coding Policy Manual for Medicare Services Chap 10: 
CPT codes 80000-89999 regarding multiple codes (page X-10). 
 
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 performance of multiple molecular tests regardless of whether the requisition lists the 
tests as a panel or individually, and completed on a single sample is considered to be a panel of tests and should 
be billed under a single CPT code to prevent stacking of codes. This rule is found in Local Coverage Article - 
Billing and Coding: Biomarkers for Oncology (A52986). 
 
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 a microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above. You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses (L33787).
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 $45 copayment for Outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page 52 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 tiered cost-sharing means a process of grouping Part D drugs into different cost sharing 
levels within a Part D sponsor's formulary. 
 
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 an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis 
of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both 
Alzheimer's Disease (AD) and fronto-temporal dementia (FTD). 
 
All other uses of FDG PET for patients with a presumptive diagnosis of dementia-causing neurodegenerative 
disease (e.g., possible or probable AD, clinically typical FTD, dementia of Lewy bodies, or Creutzfeld-Jacob 
disease) for which CMS has not specifically indicated coverage continue to be noncovered. You can find this 
rule in the National Coverage Determination: 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 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 the 
requested item or service but is limited to $100 every two years (24 months) toward the purchase of eyeglasses 
or contact lenses. You can find this information in the Plan's 2022 Eyewear Rider.
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 a microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), 
dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal 
(L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose 
functional level is 3 or above. Coverage is extended only if there is sufficient clinical documentation of 
functional need for the technologic or design feature of a given type of foot. This information must be retained 
in the treating practitioner's or prosthetist's files. 
 
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. 
 
You can find this rule in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
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 can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
You can find this rule at 42 CFR Section 422.113(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 pages 47 to 52 of the Plan's 
2021 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 the quantity of ostomy supplies needed by a beneficiary is determined primarily by the type 
of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will 
be variation according to individual beneficiary need and their needs may vary over time. The table below lists 
the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity 
needed for a particular beneficiary may be more or less than the amount listed depending on the factors that 
affect the frequency of barrier and pouch change. 
 
The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in 
the beneficiarys medical record. If adequate documentation is not provided when requested, the excess 
quantities will be denied as not reasonable and necessary. 
 
LCD shows the following are allowed: 
 
A4424: 20 
  
You can find this rule in the Local Coverage Determination (LCD) Ostomy Supplies L33828. 
 
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. 
Percutaneous Vertebral Augmentation (PVA) (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is 
covered in patients with BOTH the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression Fracture 
(VCF) (T1  L5) by recent (within 30 days) advanced imaging (bone marrow edema on Magnetic 
resonance imaging (MRI) or bone-scan/ single-photon emission computerized tomography (SPECT) 
/computed tomography (CT) uptake)
1-3,10,25,27
 
b. Symptomatic (ONE):  
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain 
score greater than or equal to 8)
4-7
 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite 
optimal non-surgical management (NSM)
10
* (ONE):  
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with greater 
than or equal to 2 of the following):  
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17) 
* consider including pedicle periosteal infiltration
7
 
     c. Continuum of care
10
 (BOTH): 
i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis 
education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
2. Exclusion criteria
2,5,8-10
 (Can have NONE of the following): a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication 
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than three vertebral fractures 
Vertebral augmentation and KYPHOPLASTY for vertebral compression fractures with intractable spinal pain 
not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma 
involving a vertebral body. 
You can find this rule in the Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for a comprehensive oral evaluation but only when received by a general participating dentist. You 
can find this information on pages 69-71 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 state that non-sterile gloves (code A4927) are only covered as dialysis supplies. You can find this 
rule at Centers for Medicare and Medicaid Services, Durable Medical Equipment Administrative Contractor 
Region A Resource Bulletin. 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A56853. 
 
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. 
Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following 
three (3) requirements are met:  
o History, physical examination, and concordant radiological image-based diagnostic testing and 
supporting one of the following.
5
  
 Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis
5
, OR 
 Post-laminectomy syndrome
6,7,8
, OR 
 Acute herpes zoster associated pain
6
 
AND 
o Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact 
quality of life or function. An objective pain scale or functional assessment must be performed 
at baseline (prior to interventions). The same scale* must be repeated at each follow-up 
assessment of response. 
        AND 
o Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative 
care or medical documentation of failure to respond to four (4) weeks of noninvasive 
conservative care or acute herpes zoster refractory to conservative management where four (4) 
week wait is not required.
9
 
Repeat ESI when the first injection directly and significantly provided improvement of the condition being 
treated may be considered medically reasonable and necessary when the medical record documents at least 
50% of sustained improvement in pain relief and/or improvement in function measured from baseline using 
SAME scale* for at least three months.
7,8
 If a patient fails to respond well to the initial ESI, a repeat ESI after 
14 days can be performed, using a different approach, level and/or medication if appropriate, with the rationale 
and medical necessity for the second ESI documented in the medical record. You can find this rule in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L39054). 
 
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 term cytogenetic studies is used to describe the microscopic examination of the physical 
appearance of human chromosomes. Medicare covers these tests when they are reasonable and necessary for 
the diagnosis or treatment of the following conditions: 
 Genetic disorders (e.g., mongolism) in a fetus; (See the Medicare Benefit Policy Chapter 15, "Covered 
Medical and Other Health Services," 20.1) 
 Failure of sexual development; 
 Chronic myelogenous leukemia; 
 Acute leukemias lymphoid (FAB L1-L3), myeloid (FAB M0-M7), and unclassified; or 
 Mylodysplasia 
You can find this rule in the Medicare National Coverage Determination (NCD)- 190.3, Cytogenetic Studies. 
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 this article tells you about updates to Chapter 10 of the Medicare Claims Processing Manual to 
include instructions for submitting Home Health (HH) NOAs instead of RAPs on and after January 4, 2022, 
through February 2, 2022. You can find this information in the Centers for Medicare & Medicaid Services 
(CMS) article Replacing Home Health Requests for Anticipated Payment (RAPs) with a Notice of Admission 
(NOA) - Manual Instructions. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.