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 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 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 Section 423.578(b)(5)(ii).
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. The health plan contract says that step therapy encourages you to try our preferred agents, which are just as effective: Monovisc and Orthovisc. The member must meet the following criteria: has had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc (step therapy requirement). You can find this rule in plan's Pharmacy and Therapeutics Viscosupplements Coverage Policy.
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 Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.
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. Krystexxa is not medically reasonable and necessary for the enrollee in this case.
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).
The rules say to bill for targeted NGS gene panel services for somatic variant detection, review CPT codes
81445 and 81450. The units of service (UOS) for an NGS gene panel is one (UOS=1). Providers must also
provide the approved DEX Z-Code identifier for the test. Effective July 1, 2017, laboratories with 1 to 4
gene(s) on their targeted NGS panel should use CPT 81479 and one (1) UOS along with their test identifier
(DEX Z-CodeTM) to represent this service on their claims. Tier 1 and/or Tier 2 individual biomarker CPT
codes should not be used for a single gene or any combination of genes when testing is performed as part of a
NGS or other multiplexing technology panel. As CGP testing is not defined as a targeted panel by MolDX, and
it is a test not currently satisfactorily described by any existing CPT code. Therefore, to report a CGP service,
test providers should use CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM for the
test. Coverage of CGP is limited to one test per surgical specimen and precludes the use of any other molecular
testing on that specimen. For NGS-based tests that do not fit under the above definitions of "targeted" or
"Comprehensive" panels, billing with the "Not Otherwise Classified" (NOC) code 81479 along with the
approved DEX Z-CodeTM identifier is appropriate. You can find this in the Local Coverage Article: Billing
and Coding: 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 that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).
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 for chiropractic services, the Plan only covers those services related to manual manipulation of the spine. Your provider must follow prior authorization requirements. You can see this on page 4-11 of the 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 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). The rules say to bill for targeted NGS gene panel services for somatic variant detection, review CPT codes 81445 and 81450. The units of service (UOS) for an NGS gene panel is one (UOS=1). Providers must also provide the approved DEX Z-Code identifier for the test. Effective July 1, 2017, laboratories with 1 to 4 gene(s) on their targeted NGS panel should use CPT 81479 and one (1) UOS along with their test identifier (DEX Z-CodeTM) to represent this service on their claims. Tier 1 and/or Tier 2 individual biomarker CPT codes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel. As CGP testing is not defined as a targeted panel by MolDX, and it is a test not currently satisfactorily described by any existing CPT code. Therefore, to report a CGP service, test providers should use CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM for the test. Coverage of CGP is limited to one test per surgical specimen and precludes the use of any other molecular testing on that specimen. For NGS-based tests that do not fit under the above definitions of "targeted" or "Comprehensive" panels, billing with the "Not Otherwise Classified" (NOC) code 81479 along with the approved DEX Z-CodeTM identifier is appropriate. You can find this in the Local Coverage Article: Billing and Coding: 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 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).
The rules say to bill for targeted NGS gene panel services for somatic variant detection, review CPT codes
81445 and 81450. The units of service (UOS) for an NGS gene panel is one (UOS=1). Providers must also
provide the approved DEX Z-Code identifier for the test. Effective July 1, 2017, laboratories with 1 to 4
gene(s) on their targeted NGS panel should use CPT 81479 and one (1) UOS along with their test identifier
(DEX Z-CodeTM) to represent this service on their claims. Tier 1 and/or Tier 2 individual biomarker CPT
codes should not be used for a single gene or any combination of genes when testing is performed as part of a
NGS or other multiplexing technology panel. As CGP testing is not defined as a targeted panel by MolDX, and
it is a test not currently satisfactorily described by any existing CPT code. Therefore, to report a CGP service,
test providers should use CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM for the
test. Coverage of CGP is limited to one test per surgical specimen and precludes the use of any other molecular
testing on that specimen. For NGS-based tests that do not fit under the above definitions of "targeted" or
"Comprehensive" panels, billing with the "Not Otherwise Classified" (NOC) code 81479 along with the
approved DEX Z-CodeTM identifier is appropriate. You can find this in the Local Coverage Article:
Billing and Coding: 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 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).
The CMS Correct Coding Initiative (CCI) has identified column I procedure codes and their associated column
II procedure codes based on the principles of correct coding. Services that are considered column II procedures
to another service are not eligible for reimbursement when billed with the column I procedure code. You can
find this information in the CMS Correct Coding Initiative (CCI).
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 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. 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. The Plan contract says that specifically listed dental services are covered by the plan. Crown (D2750) and prefabricated post and core in addition to crown (D2954) are listed as covered benefits when medically reasonable and necessary. You can find this information on pages 90 and 104 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 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).
The rules say to bill for targeted NGS gene panel services for somatic variant detection, review CPT codes
81445 and 81450. The units of service (UOS) for an NGS gene panel is one (UOS=1). Providers must also
provide the approved DEX Z-Code identifier for the test. Effective July 1, 2017, laboratories with 1 to 4
gene(s) on their targeted NGS panel should use CPT 81479 and one (1) UOS along with their test identifier
(DEX Z-CodeTM) to represent this service on their claims. Tier 1 and/or Tier 2 individual biomarker CPT
codes should not be used for a single gene or any combination of genes when testing is performed as part of a
NGS or other multiplexing technology panel. As CGP testing is not defined as a targeted panel by MolDX, and
it is a test not currently satisfactorily described by any existing CPT code. Therefore, to report a CGP service,
test providers should use CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM for the
test. Coverage of CGP is limited to one test per surgical specimen and precludes the use of any other molecular
testing on that specimen. For NGS-based tests that do not fit under the above definitions of "targeted" or
"Comprehensive" panels, billing with the "Not Otherwise Classified" (NOC) code 81479 along with the
approved DEX Z-CodeTM identifier is appropriate. You can find this in the Local Coverage Article (LCA):
Billing and Coding: 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 that a Medicare plan may not pay for services given by a physician or other practitioner who has opted out of Medicare. This rule does not apply to emergency or urgently needed services. This rule applies to all other services, as well as to supplemental benefits. A Medicare plan must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Medicare Managed Care Manual, Chapter 6, Section 60.2.
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 While you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. You can find this information on page 29 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 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 each Medicare-covered emergency room visit. You can find this information on page 64 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 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).
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.
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 pays for an assistant at surgery only when the procedure is authorized for an assistant. The assistant must be a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS). Medicare does not pay for assistant at surgery services performed by a person who bears any title or license other than those listed. You can find this rule in the Medicare Claims Processing Manual, Chapter 4, Section 250.9. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR 424.5.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that a modifier is used to indicate a distinct procedural service. This may represent a different
session or patient encounter, different procedure or surgery, different site, or organ system, separate
incision/excision, or separate injury. You can find this rule in the Medicare Claims Processing Manual, Chapter
23, Section 20.9.1.1B.
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).
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 when submitting a claim for compounded drug(s) for a single agent or a combination of agents, providers must use HCPCS code J7999KD. Even though the compound is similar to or includes a drug with a specific HCPCS code, providers must use HCPCS code J7999, Compounded drug, not otherwise classified, for reimbursement of the compounded drug. The KD modifier must be appended to indicate the drug will be administered through a DME. You can find this rule in Local Coverage Article: Compounded Drugs Used in an Implantable Infusion Pump (A54100).
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 on page 29 of the 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 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).
The hydration codes are used to report a hydration IV infusion which consists of a pre-packaged fluid and /or
electrolytes (e.g. normal saline, D5-1/2 normal saline +30 mg EqKC1/liter) but are not used to report infusion
of drugs or other substances. The fluid used to administer the drug (s) is incidental hydration and is not
separately payable. You can find this rule in the Medicare Claims Processing Manual, Chapter 12, Section
30.5.
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.