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 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 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 38 of the plan's 2019 
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 Guardant360 testing must be billed with Current Procedural Terminology (CPT) code 
81479 for date of service May 6, 2020. You can find this rule in Local Coverage Article (LCA) Billing and 
Coding: MolDX: Guardant360 Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung 
Cancer (NSCLC) (A57425). 
 
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 20% coinsurance for Medicare Part B covered drugs and a $25 copayment 
for consultation, diagnosis, and treatment by a specialist. You can find this information on pages 72-73 and 80 
of the Plan's 2020 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 claims for A9279 (MONITORING FEATURE/DEVICE, STAND-ALONE OR 
INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, COMPONENTS AND ELECTRONICS, 
NOT OTHERWISE CLASSIFIED) are denied as statutorily non-covered (No Medicare benefit). You can find 
this rule in Local Coverage Article: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive 
Sleep Apnea - Policy Article (A52467). 
 
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 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 you can see this on page 13 of 
the 2019 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 providers must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
To report a Guardant360 service for NSCLC, please submit the following claim information: 
Enter 1 unit of service (UOS) 
Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for 
the following Part B claim field/types: 
Loop 2400 or SV101-7 for the 5010A1 837P 
Item 19 for paper claim 
Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for 
the following Part A claim field/types: 
Line SV202-7 for 837I electronic claim 
Block 80 for the UB04 claim form 
Select the appropriate ICD-10-CM code 
You can find this information in Local Coverage Article: Billing and Coding: MolDX: Guardant360 Plasma-
Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) (A57425). 
 
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 certain diagnostic tests which are often performed routinely prior to surgical procedures and 
do not meet the definition of reasonable and necessary include: 
-Electrocardiograms performed pre-operatively, when there are no indications for this test 
-Radiologic examination of the chest performed pre-operatively, when there are no indications for this test 
 
Claims submitted for these tests performed solely as part of a preoperative examination, without additional 
diagnoses indicating medical necessity, will be denied as not reasonable and necessary. You can find this rule 
in Local Coverage Determination (LCD) Non-Covered Services (L33629). 
 
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 comprehensive genomic profile (CGP) testing is not defined as a targeted panel by MolDX, 
and it is a test not currently satisfactorily described by any existing Current Procedural Terminology (CPT) 
code. Therefore, to report a CGP service, test providers should use CPT code 81479 for date of service March 
24, 2020, in addition to the approved DEX Z-Code for the test. You can find this rule in Local Coverage 
Article (LCA) MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in 
Cancer (A55624). 
 
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 $230 copayment per day for days 17 of inpatient mental health care. 
You can find this information on page 71 of the Plan's 2019 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 $300 copayment for surgery in an outpatient hospital facility. You can 
find this information on page 98 of the Plan's 2020 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 a spinal orthosis (including code L0650) is covered when it is ordered for one of the 
following indications: 
1. To reduce pain by restricting mobility of the trunk; or 
2. To facilitate healing following an injury to the spine or related soft tissues; or 
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or 
4. To otherwise support weak spinal muscles and/or a deformed spine 
 
You can find this rule in Local Coverage Determination (LCD) Spinal Orthoses: TLSO and LSO (L33790). 
 
The rules state that if a supplier delivers a lumbar-sacral orthosis (L0650) prior to receipt of a written order 
prior to delivery (WOPD), it will be denied as not reasonable and necessary. If the WOPD is not obtained prior 
to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If 
a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible 
for coverage. You can find this rule in Local Coverage Article (LCA) Spinal Orthoses: TLSO and LSO Policy 
Article (A52500). 
 
The rules state that a written order prior to delivery (WOPD) is a completed standard written order (SWO) that 
is communicated to the supplier before delivery of the items. The order must contain all of the following 
elements: 
? Beneficiary's name or Medicare Beneficiary Identifier (MBI) 
? Order Date 
? General description of the item 
o The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS 
code, a HCPCS code narrative, or a brand name/model number 
o For equipment - In addition to the description of the base item, the SWO may include all 
concurrently ordered options, accessories or additional features that are separately billed or 
require an upgraded code (List each separately). 
o For supplies ? In addition to the description of the base item, the DMEPOS order/prescription 
may include all concurrently ordered supplies that are separately billed (List each separately) 
? Quantity to be dispensed, if applicable 
? Treating Practitioner Name or NPI 
? Treating practitioner's signature 
 
You can find this rule in Local Coverage Article (LCA) Standard Documentation Requirements for All Claims 
Submitted to DME MACs (A55426). 
 
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 Guardant360 testing must be billed with Current Procedural Terminology (CPT) code 
81479 for date of service March 11, 2020. You can find this rule in Local Coverage Article (LCA) Billing and 
Coding: MolDX: Guardant360 Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung 
Cancer (NSCLC) (A57425). 
 
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 $25 copayment for carotid or peripheral vascular ultrasounds. You can 
find this information in Chapter 4 on page 74 of the Plan's 2020 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 $45 copayment for services obtained from a specialist, or under 
circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care 
professionals in a specialist's office. You can find this information on pages 4-36 to 4-39 of the Plan's 2019 
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). 
 
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the 
care of the enrollee in accordance with Medicare policies.  
You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking 
Corrective Actions, Section 3.3.2.4 entitled Signature Requirements. 
 
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 $20 copayment for chiropractic services. You can find this information 
in Chapter 4 on page 53 of the Plan's 2019 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 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 SSA, Section 1862(a)(12) and 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 includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Unspecified preventive procedure (D1999) is not included on this list and is 
not a covered supplemental benefit. You can find this information on pages 4-53 to 4-57 of the Plan's 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 patient's medical records must establish medical necessity for a hospital bed due to one of the following reasons:

1. The patient's condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or 

2. The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. 
You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(A).

In order to qualify for a semi-electric hospital bed, the patient's condition must require frequent change in body position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last requirement in cases of spinal cord injury and brain damaged patients. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.7(D).
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 SSA, Section 1862(a)(12) and 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 includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Maxillary partial denture (D5225) is not included on this list and is not a 
covered supplemental benefit. You can find this information on pages 4-80 to 4-88 of the Plan's 2020 Evidence 
of Coverage.