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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 health 
plan contract says up to a $1,000 allowance for hearing aids every three (3) years. You can find this 
information in Chapter 4 on page 4-18 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 Section 1862 of the Social Security Act requires that an item or service must be "reasonable 
and necessary" before payment may be made. A reasonable and necessary determination is largely based on a 
review of the published clinical literature that is relevant to the item under consideration. When there is no 
published policy for an item, the Durable Medical Equipment (DME) Medicare Administrative Contractor 
(MAC) may still make individual determinations when reviewing claims. The DME MAC medical directors 
have reviewed information about the products billed using code E0118. The determination is that there is 
insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to 
establish the medical necessity for these products.  
You can find this information in an article entitled "E0118 - Crutch Substitute" on the DME MAC website at 
https://cgsmedicare.com/jc/pubs/news/2010/0210/cope11657.html 
 
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 restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 24 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 the term Medicare beneficiary identifier (MBI) is a general term describing a beneficiary's 
Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both 
the Health Insurance Claim Number (HICN) and the MBI during the new Medicare card transition period and 
after for certain business areas that will continue to use the HICN as part of their processes. Exact duplicates 
are controlled by the claims processing system through 'hard coded' edits, and may not be user-controlled.  In 
addition, Medicare contractors cannot override or bypass exact duplicate edits. You can find this information in 
the Medicare Claims Processing Manual Chapter 1 - General Billing Requirements. 
 
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 right heart catheterization is indicated to evaluate: 
1. Valvular heart disease; 
2. Congestive heart failure; 
3. Congenital heart disease; 
4. Cor pulmonale; 
5. Pulmonary hypertension; 
6. Intracardiac shunts (including septal rupture) and extracardiac vascular shunts; 
7. Suspected cardiomyopathy or myocarditis; 
8. Endocarditis anticipated to require valvular surgical repair; 
9. Suspected rejection of a transplanted heart; 
10. Suspected pericardial tamponade or constriction. 
 
You can find this rule in the Local Coverage Determination (LCD): Cardiac Catheterization and Coronary 
Angiography (L33557) effective October 1, 2019. 
 
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 elective hysterectomy, tubal ligation, and vasectomy, if the primary indication for these 
procedures is sterilization, are not covered. You can find this rule in the National Coverage Determination 
Manual Chapter 1, Section 230.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 neurostimulator device is listed under the Food and Drug Administration (FDA) approval 
documents as electro-acupuncture devices used for stimulation of auricular acupuncture points and as such are 
non-covered. You can find this rule at Local Coverage Article: Billing and Coding: Auricular Peripheral Nerve 
Stimulation (Electro-Acupuncture Device) (A55240) (eff. 1/21/20). 
 
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 restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 10.
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 repetitive transcranial magnetic stimulation (rTMS) is only considered medically necessary 
in adults who have a confirmed diagnosis of major depressive disorder (MDD), single or recurrent episode and 
meet the following criteria: 
- Resistance to treatment as evidenced by a lack of a clinically significant response to four (4) trials of 
psychopharmacologic agents in the current depressive episode;  
- Two different agent classes, at or above the minimum effective dose and duration and includes 
trials of at least two (2) evidence-based augmentation therapies; or 
- Inability to tolerate psychopharmacologic agents as evidenced by four (4) trials of 
psychopharmacologic agents with distinct side effects; or  
- History of response to rTMS in a previous depressive episode; or 
- History of response to electroconvulsive therapy (ECT) in a previous or current MDD episode, or 
inability to tolerate ECT, and rTMS is considered a less invasive treatment option; and 
- A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an 
adequate frequency and duration without significant improvement in depressive symptoms as 
documented by standardized rating scales that reliably measure depressive symptoms; and 
- The rTMS treatment is delivered by a device that is FDA-approved or cleared for the treatment of 
MDD in a safe and effective manner. rTMS treatment should generally follow the protocol and 
parameters specified in the manufacturer's user manual, with modifications only as supported by the 
published scientific evidence base; and  
- The order for treatment (or re-treatment) is written by a physician (MD or DO) who has examined the 
patient and reviewed the record. The physician must have experience in administering rTMS therapy 
and the treatment must be given under direct supervision of this physician, i.e., he or she must be in the 
area and be immediately available. 
You can find this rule in the Local Coverage Determination (LCD): Transcranial Magnetic Stimulation 
(L33398) effective October 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 that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41. 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Medicare Managed Care Manual, 
Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. The Plan 
contract says that we cover routine transportation for up to 60 one-way transportation trips per calendar year. 
You can find this information on page 4-76 of the 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 Medicare pays for the routine costs of qualifying clinical trials, as well as reasonable and 
necessary items and services used to diagnose and treat complications arising from participation in all clinical 
trials.  Routine costs of a clinical trial include all items and services that are otherwise generally available to 
Medicare beneficiaries that are provided in either the experimental or the control arms of a clinical trial except: 
- The investigational item or service, itself; 
- Items and services provided solely to satisfy data collection and analysis needs and that are not used in 
the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a 
single scan); and 
- Items and services customarily provided by the research sponsors free of charge for any enrollee in the 
trial. 
 
Routine costs in clinical trials include: 
- Items or services that are typically provided absent a clinical trial (e.g., conventional care); 
- Items or services required solely for the provision of the investigational item or service (e.g., 
administration of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of 
the item or service, or the prevention of complications; and 
- Items or services needed for reasonable and necessary care arising from the provision of an 
investigational item or service - in particular, for the diagnosis or treatment of complications. 
 
You can find this rule at Medicare National Coverage Determinations Manual, Chapter 1, Section 310.1. 
 
The rules say that effective for claims with dates of service on or after January 1, 2014, it is mandatory to 
report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under 
CED. You can find this rule in the Medicare Claims Processing Manual, Chapter 21, Section 69.2. 
 
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.
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) non-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. You 
can find this information on page 62 of the 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. 
 
Medicare guidance says, "The fluid used to administer the drug (s) is incidental hydration and is not separately 
payable. You can find this Medicare guidance 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.
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.  Nationally Covered Conditions 
 
    Payment may be made only where sterilization is a necessary part of the treatment of an illness or injury, 
e.g., removal of a uterus because of a tumor, removal of diseased ovaries. 
 
    Sterilization of a mentally challenged beneficiary is covered if it is a necessary part of the treatment of an 
illness or injury (bilateral oophorectomy or bilateral orchidectomy in a case of cancer of the prostate). The 
Medicare Administrative Contractor denies claims when the pathological evidence of the necessity to perform 
any such procedures to treat an illness or injury is absent; and 
 
    Monitor such surgeries closely and obtain the information needed to determine whether in fact the surgery 
was performed as a means of treating an illness or injury or only to achieve sterilization. 
 
B.       Nationally Non-Covered Conditions 
 
    Elective hysterectomy, tubal ligation, and vasectomy, if the primary indication for these procedures is 
sterilization; 
 
    A sterilization that is performed because a physician believes another pregnancy would endanger the overall 
general health of the woman is not considered to be reasonable and necessary for the diagnosis or treatment of 
illness or injury within the meaning of 1862(a)(1) of the Social Security Act. The same conclusion would 
apply where the sterilization is performed only as a measure to prevent the possible development of, or effect 
on, a mental condition should the individual become pregnant; and sterilization of a mentally retarded person 
where the purpose is to prevent conception, rather than the treatment of an illness or injury. 
 
You can find this information in Medicare's National Coverage Determination (NCD) for Sterilization (230.3). 
 
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. 
 
Medicare guidance says, "All items and non-physician services furnished to inpatients must be furnished 
directly by the hospital or billed through the hospital under arrangements. This provision applies to all 
hospitals, regardless of whether they are subject to PPS." You can find this guidance in the Medicare Claims 
Processing Manual Chapter 3 - Inpatient Hospital Billing 10.4 - Payment of  Non-physician Services for 
Inpatients. 
 
Medicare guidance says "For purposes of this provision, the term 'physician' is limited to doctors of medicine; 
doctors of osteopathy; doctors of dental surgery or of dental medicine; doctors of podiatric medicine; and 
doctors of optometry who are legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery 
by the State in which such function or action is performed; no other physicians may opt out. Also, for purposes 
of this provision, the term 'practitioner' means any of the following to the extent that they are legally 
authorized to practice by the State and otherwise meet Medicare requirements." You can find this guidance in 
the Medicare Benefit Policy Manual Chapter 15 - Covered Medical and Other Health Services; 40.4 - 
Definition of Physician/Practitioner. 
 
Medicare guidance says "Items and services excluded by statute cannot necessarily be recognized in specific 
procedure or diagnosis codes. For example, in some cases, a given code may be covered as part of a given 
Medicare benefit, but under other cases, when no benefit exists, the same code would not be covered by 
Medicare. For claims submitted to Medicare contractors, these services that are not Medicare benefits may 
be:(A) Not submitted to Medicare at all (see A, immediately below),(B) Submitted as non-covered line items, 
or(C) Submitted on entirely non-covered claims." You can find this guidance in the Medicare Claims 
Processing Manual, Publication 100-04, Chapter 1, Section 60.1.2.-Billing Services Excluded by Statute. 
 
Medicare guidance says "2019 Physician Fee Schedule January Release Procedure code 99190 and status code 
X. status Code X - Statutory Exclusion: These codes represent an item or service that is not in the statutory 
definition of physician services for fee schedule payment purposes. No RVUS or payment amounts are shown 
for these codes, and no payment may be made under the physician fee schedule. (Examples are ambulances 
services and clinical diagnostic laboratory services.)" You can find this guidance in the 2019 Physician Fee 
Schedule January Release and Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration 
and Coding Requirements, Sec 30.2.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.