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 Indications: Ventricular Function, Cardiomyopathies and Heart Failure. 
 
1. When the etiology is in doubt, echocardiography can document or rule out the common cardiac causes 
of pulmonary congestion: left-sided valvular disease, depressed systolic or diastolic function, and 
cardiomyopathy. In this regard, echocardiography is the preferred initial diagnostic test when the 
history, physical examination, and routine laboratory tests suggest (or cannot eliminate) cardiac 
disease." (ACC/AHA/ASE 2003 Guideline Update, pg. 35) 
2. Echocardiography is recommended for patients with edema with clinical signs of elevated central 
venous pressure when a potential cardiac etiology is suspected or when central venous pressure cannot 
be estimated with confidence and clinical suspicion of heart disease is high." TTE is also recommended 
for patients experiencing "dyspnea with clinical signs of heart disease."(ACC/AHA/ASE 2003 
Guideline Update, pg. 37) 
3. Echocardiography is not recommended in patients with edema when the jugular venous pressure does 
not appear to be elevated." (ACC/AHA/ASE 2003 Guideline Update, pg. 35). 
 
You can find this rule at the Medicare Local Coverage Determination (LCD)- L33577, Transthoracic 
Echocardiography (TTE). 
 
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 orally administered enteral nutrition products, related supplies and equipment will be 
denied non-covered, no benefit. 
You can find these rules in the Local Coverage Article 
Enteral Nutrition - Policy Article, A58833. 
 
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 $60.00 copayment per provider, per date of service for radiology 
services. You can find this information in Chapter 4 on pages 89-93 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 the GY modifier is to be used when physicians, practitioners, or suppliers want to indicate 
that the item or service is statutorily non-covered or is not a Medicare benefit. You can find this rule at Centers 
for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing 
Transmittal 2148, Change Request 7228. 
 
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 $300 copayment per one-way trip by ground or air ambulance. You can 
find this information on page 63 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 say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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 In-Home Support Services provided immediately following discharge from the hospital or 
skilled nursing facility to assist with activities of daily living, pick up medications, and shop for groceries and 
necessities. The contract also says if you meet certain clinical criteria immediately following discharge from a 
hospital or skilled nursing facility, you may qualify to receive non-clinical personal care services at home for 
assistance with activities of daily living (e.g., bathing, dressing, light household chores) through the plan's 
contracted vendor. You can find this information on pages 72 and 73 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 30.2.2. 
 
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 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 $110 radiological diagnostic service copayment for outpatient 
diagnostic tests and therapeutic services and supplies. You can find this information on page 4-31 to 4-35 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 say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator P means there are no RVUs and no payment 
amounts for these services. No separate payment should be made for them under the fee schedule. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
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. 
 
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(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 includes a list of covered vision care benefits. Contact lens fitting (92310) is not included on this list, 
and is not a covered supplemental benefit. The contract also says that Original Medicare does not cover routine 
eye exams (eye refractions) for eyeglasses/contacts, even after surgery. Refraction is only covered when 
performed as part of a routine vision eye exam by an optometrist. You can find this information on pages 113 
and 114 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that computed tomography perfusion (CTP) (using automated post-processing software 
algorithmic analysis) is medically reasonable and necessary in patients with acute ischemic stroke (AIS) caused 
by unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers; CTP 
can be used to aid in selection for endovascular mechanical thrombectomy (EVT) if one of the following other 
conditions is fulfilled: 
 
1. Treatment (femoral puncture) can be started within 6-24 hours of the time last known to be at 
neurologic baseline and who meet the pre-CTP inclusion/exclusion criteria as defined by the DAWN 
trial, or 
2. Treatment (femoral puncture) can be started within 6-16 hours of the time last known to be at 
neurologic baseline and who meet the pre-CTP inclusion/exclusion criteria as defined by the DEFUSE 
3 trial 
 
You can find this information in Local Coverage Determination (LCD): Computed Tomography Cerebral 
Perfusion Analysis (L38700). 
 
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 respiratory panels with more than five respiratory pathogens performed in the Part B 
outpatient setting are not considered medically reasonable and necessary. You can find this rule in the Local 
Coverage Determination (LCD) - Respiratory Pathogen Panel Testing (L38916). 
 
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 $300 copayment for each day one through six for inpatient hospital care. 
You can find this information on page 4-29 through 4-32 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 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 $200 copayment per visit for wound care services. You can find this 
information in Chapter 4 on pages 61-62 of the Plan's 2021 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 a Pneumatic Compression Device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare DME benefit. A PCD coded as 
E0675 to treat peripheral arterial disease is not eligible for reimbursement. There is insufficient evidence to 
demonstrate that reimbursement is justified. Claims for E0675 will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Article: Pneumatic Compression Devices - Policy Article 
(A52488) and in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). 
 
Medicare guidance says Medicare rules say that the facility or hospital must furnish all necessary covered 
services to the beneficiary either directly or under arrangements made between the facility hospital and outside 
providers. Applicable payments are payment in full for all facility or hospital services, as defined in 42 CFR 
409.10. Centers for Medicare & Medicaid Services (CMS) does not pay any provider or supplier other than the 
facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary 
covered services to the beneficiary either directly or under arrangements (as defined in 42 CFR 409.32). You 
can see this in 42 CFR 412.50. 
 
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 Pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
    The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
 
    The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the FDA table of known gene-drug interactions where data support therapeutic 
recommendations or a potential impact on safety or response or the FDA 
label; https://www.fda.gov/drugs/science-and-research-drugs/table-pharmacogenomic-biomarkers-drug-
labeling; https://www.fda.gov/medical-devices/precision-medicine/table-pharmacogenetic-associations  
 
Some panel/combinatorial tests may include content that has demonstrated actionability and some that has not. 
In these circumstances, the components of the tests that have demonstrated actionability as noted in #2 will be 
considered medically reasonable and necessary. Refer to the related billing and coding article for coding 
information. 
 
Please refer to National Coverage Determination (NCD) 90.1 for anticoagulation dosing with warfarin. 
 
Limitations 
 
The following is considered not medically reasonable and necessary: 
 
    Genetic testing where either analytical validity, clinical validity, or clinical utility has not been established. 
    Germline testing may be performed once in a lifetime per beneficiary. 
        Any laboratory test that investigates the same germline genetic content, for the same genetic information, that has already been tested in the same Medicare beneficiary is not medically reasonable and necessary as it is 
duplicative. The germline sequence of an individual does not change over time, and therefore repeat testing of 
the same germline content for the same genetic information does not provide new clinical information. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pharmacogenomics Testing 
(L39073). 
 
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 claims or claim lines that have been determined to be an exact duplicate are rejected and do 
not have appeal rights. An exact duplicate for institutional claims is a claim or claim line that exactly matches 
another claim or claim line with respect to the following elements: 
 Medicare beneficiary identifier;  
Type of Bill; 
 Provider Identification Number; 
 From Date of Service; 
 Through Date of Service; 
 Total Charges (on the line or on the bill); and 
 HCPCS, CPT-4, or Procedure Code modifiers. 
 
You can find this information in the Medicare Claims Processing Manual Chapter 1 - General Billing 
Requirements: 120.2 - Exact Duplicates (Rev. 4201, Issued: 01-18-19, Effective: 02-19-19, Implementation: 
02-19-19). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.