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 payment may be made for the replacement of a prosthetic device that is an artificial limb, or 
replacement part of a device if the ordering physician determines that the replacement device or part is 
necessary because of any of the following: 
 
1. A change in the physiological condition of the patient; 
2. An irreparable change in the condition of the device, or in a part of the device; or 
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120. 
 
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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 pages 44 and 48-49 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 panels with greater than five respiratory pathogens performed in the Part B outpatient 
setting are not medically necessary. 
You can find these rules in the Local Coverage Determination (LCD) for 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 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 also says that covered chiropractic services include manual manipulation of the spine to correct 
subluxation. Excluded from Medicare coverage is any service other than manual manipulation for the treatment 
of subluxation. You can find this information on page 4-11 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 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 worldwide emergency care applies to emergency care outside the United States and its 
territories. Coverage includes: Services furnished by a provider qualified to furnish emergency services and 
needed to evaluate or stabilize an emergency medical condition, as well as services provided after stabilization 
and provided to maintain the condition. Post-stabilization services end at discharge. There is a $75 copayment 
for worldwide emergency care. You can find this information on page 70 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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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 claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected. Some claims that 
appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances 
of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers 
of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may 
appear to be duplicates, but, in fact, are not. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, 
Section 120.1. 
 
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.
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 repeat series of hyaluronan knee injection(s) for patients who have responded to a prior 
series is considered to be reasonable and necessary under the following circumstances: 
 Symptoms have recurred 
And, 
 At least six months have elapsed since the prior series of injections 
And, 
 There was significant improvement in pain and functional capacity achieved with the prior series of 
injections using a standardized assessment tool 
Or, 
 There is significant reduction in the doses of NSAID medications taken or reduction in the number of 
intra-articular steroid injections to the knees during the six-month period following the injection(s). 
 
You can find this information in Local Coverage Determination (LCD): Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427). 
 
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 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 the reasonable useful lifetime of durable medical equipment is determined through program 
instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful 
lifetime of equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on 
when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is 
not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, 
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary 
equipment owned by the beneficiary. You can find this rule in the Medicare Benefit Policy Manual for Repair 
and Replacement of Durable Medical Equipment (DME): section 110.2. 
 
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. 
An epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following 
three (3) requirements are met: 
 History, physical examination, and concordant radiological image-based diagnostic testing 
supporting one of the following
5
: 
o Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis
5
; OR 
o Post-laminectomy syndrome
6-8
; OR 
o Acute herpes zoster associated pain
6
 
AND 
 Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact 
quality of life or function. An objective pain scale or functional assessment must be performed 
at baseline (prior to interventions). The same scale* must be repeated at each follow-up for 
assessment of response.  
AND 
 Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative 
care or medical documentation of failure to respond to four (4) weeks of noninvasive 
conservative care or acute herpes zoster refractory to conservative management where a four (4) 
week wait is not required.
9
 
You can find this rule in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L39240). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that The Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations 
Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 stipulates that ventilators (E0465, E0466, and 
E0467) are covered for the following conditions: 
 
[N]euromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. 
 
Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to 
less serious forms. These ventilator-related disease groups overlap conditions described in this Respiratory 
Assist Devices LCD used to determine coverage for bi-level PAP devices. Each of these disease categories are 
conditions where the specific presentation of the disease can vary from beneficiary to beneficiary. For 
conditions such as these, the specific treatment plan for any individual beneficiary will vary as well. Choice of 
an appropriate treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made 
based upon the specifics of each individual beneficiary's medical condition. In the event of a claim review, 
there must be sufficient detailed information in the medical record to justify the treatment selected. 
 
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy 
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway 
pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means that 
products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-level 
PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in 
the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in 
this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP 
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions 
described in this RAD policy will be denied as not reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination (LCD) for Respiratory Assist Devices (L33800). 
 
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 does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-16, 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 reimburses you up to $250 per calendar year towards your cost for membership in a qualified 
health club or fitness facility during the calendar year, covered instructional fitness classes, participation in 
wellness programs such as Matter of Balance, Chronic Disease self-management, diabetes workshop, Healthy 
Eating for Successful Living, Healthy IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise, 
Enhance Wellness, Fit For Your Life, AAA Senior Driving, memory fitness activities, acupuncture, and/or 
covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician. You pay all 
charges over $250 per calendar year. You can find this information on pages 84 and 85 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 testing 
 
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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 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 pages 42 to 47 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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 
The rules say that Medicare covers lipid panel testing as cardiovascular screening once every 5 years and 
denies coverage for all cardiovascular genetic risk assessment panels for patients with suspected or documented 
cardiovascular disease.  You can find this rule in 42 CFR 410.17 Cardiovascular disease screening tests, 
Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services  1.2  Table of 
Preventive and Screening Services.  
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 home health agencies (HHAs) shall no longer submit Requests for Anticipated Payment 
(RAPs) on Type of Bill (TOB) 0322 for any HH period of care with a From date on or after January 1, 2022. 
Instead, for each admission to home health, the HHA notifies Medicare systems via submission of a Notice of 
Admission (NOA). 
 
For all beneficiaries receiving HH services in 2021 whose services will continue in 2022, the HHA shall submit 
an NOA with a one-time, artificial 'admission' date corresponding to the "From" date of the first period of 
continuing care in 2022. For example, if a period of care begins in 2021 and ends on January 10, 2022, the 
HHA submits and NOA with an admission date of January 11, 2022, and then submits a claim when the 30-day 
period of care is over. The HHA should submit the January 11, 2022, admission date on all subsequent claims 
until the beneficiary is discharged and another NOA is required. This is to ensure the claim is matched to the 
correct NOA and the correct receipt date is used for payment. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.10.2. 
 
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.