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 all home health agencies must submit a request for anticipated payment (RAP), which is to 
be paid at 0 percent, within 5 calendar days after the start of care and within 5 calendar days after the from 
date for each subsequent 30-day period of care. 
You can find this rule in the 42 Code of Federal Regulations (CFR) Section 484.205, for calendar year 2021. 
 
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 implantable infusion pumps are covered for specific indications only. You can find this rule 
in the Center for Medicare Services (CMS) Publication 100-03, Medicare National Coverage Determination 
(NCD) Manual, Section 280.14. 
 
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 coding of sequela generally requires two codes sequenced in the following order: the 
condition or nature of the sequela is sequenced first. The sequela code is sequenced second. 
 
An exception to the above guidelines are those instances where the code for the sequela is followed by a 
manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, 
fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or 
injury that led to the sequela is never used with a code for the late effect. 
 
You can find this rule in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
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 services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable 
and necessary. You can find this information under L39402 Local Coverage Determination. 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
a. Patient has: 
 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
b. The diagnostic laboratory test using NGS must have: 
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in the National Coverage Determination (NCD)  Next Generation Sequencing (NGS) 
(90.2)  Effective January 27, 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 if the Medicare Fee Schedule Database contains an assistant at surgery indicator of 0 for a 
surgical procedure, assistant at surgery services are generally not medically necessary. Assistant at surgery 
services will not be paid unless supporting documentation is submitted to establish medical necessity. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 40.8(D). 
 
The rules say that Procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the AS 
modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-
at-surgery policy. Accordingly, pay claims for procedures with these modifiers only if the services of an 
assistant-at-surgery are authorized. Chapter 12, Section 20.4.3. 
 
Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when qualified resident surgeon not 
available) is used to bill for assistant at surgery services. When billed without modifier AS (PA, NP or CNS 
services for assistant at surgery) the use of these modifiers indicate that a physician served as an assistant at 
surgery. Modifier AS is billed to indicate that a PA, NP or CNS served as the assistant at surgery. Modifier 80, 
81 or 82 must also be billed when modifier AS is billed. Claims submitted with modifier AS and without 
modifiers 80, 81 or 82 are returned to the provider (RTPd). You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 4, Section 250.9. 
 
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 portable oxygen system is covered if the beneficiary is mobile within the home for Groups 
I and II, and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only 
qualifying blood gas study was performed during sleep, portable oxygen will be denied as not reasonable and 
necessary. 
 
If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary 
system. See exception in the LCD-related Policy Article Non-Medical Necessity Coverage and Payment Rules, 
OXYGEN EQUIPMENT, Initial 36-Months section. 
 
If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the beneficiary 
uses; Medicares reimbursement is the same, regardless of the quantity of oxygen dispensed. 
 
LITER FLOW GREATER THAN 4 LPM: 
 
If initial oxygen coverage criteria for Group I, II or III have been met, a higher allowance for a stationary 
system for a flow rate of greater than 4 liters per minute (LPM) will be paid. For Group I or II, coverage greater 
than 4 LPM requires a qualifying blood gas study performed while the beneficiary is on 4 or more LPM. If a 
flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment 
will be limited to the standard fee schedule allowance. (Refer to the LCD-related Policy Article for additional 
information on payment for greater than 4 LPM oxygen.) 
 
You can find these rules in the Local Coverage Determination (LCD) Oxygen and Oxygen Equipment 
L33797. 
 
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/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 procedures and examinations which are not covered under the portable x-ray provision 
include the following: 
1. Procedures involving fluoroscopy; 
2. Procedures involving the use of contrast media; 
3. Procedures requiring the administration of a substance to the patient or injection of a substance into the 
patient and/or special manipulation of the patient; 
4. Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor 
of osteopathy or which require that medical judgment be exercised; 
5. Procedures requiring special technical competency and/or special equipment or materials; 
6. Routine screening procedures; and 
7. Procedures which are not of a diagnostic nature. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Benefit Policy Manual- 
Chapter 15, Section 80.4.4 
 
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 1-7 to 1-8 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules also say that definitive drug testing is indicated when: 
 
    -The results of the screen are presumptively positive. 
    -Results of the screen are negative, and this negative finding is inconsistent with the patient's medical 
history. 
    -This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive 
test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids 
 
You can find this information in Local Coverage Determination (LCD): Drug Testing (L34645). 
 
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The rules define a chronically ill enrollee as one who has one or more 
comorbid and medically complex chronic conditions that meet all of the following: 
1. Is life threatening or significantly limits the overall health or function of the enrollee; 
2. Has a high risk of hospitalization or other adverse health outcomes; and  
3. Requires intensive care coordination. 
The rules also say that the Plan must have written policies for determining enrollee eligibility and must 
document its determination that an enrollee is a chronically ill enrollee. You can find this information in 42 
CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find this information on pages 55 and 
103-104 of the Plan's 2023 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 Current Procedural Terminology (CPT) codes 99217-99220, 99224-99226, 99318, 99324-
99328, 99334, 99335, and 99337 were deleted January 1, 2023. You can find this information in Medicare's 
National Correct Coding Initiative Policy Manual, Chapter XI: Medicine Evaluation and Management Services 
CPT Codes 90000 - 99999. 
 
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 each beneficiary has a lifetime reserve of 60 days of inpatient hospital services to draw 
upon after having used 90 days of inpatient hospital services in a benefit period. Payment will be made for such 
additional days of hospital care after the 90 days of benefits have been exhausted unless the individual elects 
not to have such payment made (and thus saves the reserve days for a later time). You can find this information 
in the Medicare Benefit Policy Manual, Chapter 5 - Lifetime Reserve Days, 10 - Summary of Provision. 
 
The rules say that hospitals are required to notify patients who have already used or will use 90 days of benefits 
in a benefit period that they can elect not to use their reserve days for all or part of a stay. The hospital notice 
should be given when the beneficiary has five regular coinsurance days left and is expected to be hospitalized 
beyond that period. Where the hospital discovers the patient has fewer than five regular coinsurance days left, it 
should immediately notify the patient of this option. The hospital should annotate its records at the time that it 
informed the patient of this option. In addition, it should make available an appropriate election statement or 
form to be included in the patient's hospital record if the patient elects not to use reserve days. (See Section 
40.1 for sample election format). You can find this in the Medicare Benefit Policy Manual, Chapter 5 - 
Lifetime Reserve Days, 30.1  General. 
 
The Plan contract says that the Plan will cover 90 days of inpatient hospital care for each benefit period. The 
plan also covers 60 lifetime reserve days. These are extra days that the Plan covers. If your hospital stay is 
longer than 90 days, you can use these extra days. You can find this information on pages 43-44 of the Plans 
2022 EOC. 
 
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 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 Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a list of 
dental services that are covered for you. Partial dentures are not on the list and therefore not covered by the 
Plan's dental benefit. You can find this information in Chapter 4 on pages 76 to 77 of the Plans 2023 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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. You can find this rule at 42 CFR Section 422.111(a) and (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 the enrollee must have tried and failed the preferred glucose test strip/disk product that is 
covered by plan. You can find this information in Chapter 4 on page 72 of the Plan's 2023 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 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(a). 
 
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 
doctors 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 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 covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 24 one-way trips each year. You can find this information on pages 89-90 of the Plans 2023 
Evidence of Coverage (EOC).