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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules state that Medicare requires that services provided/ordered/certified be authenticated by the persons 
responsible for the care of the beneficiary in accordance with Medicare's policies. The method used shall be a 
handwritten or electronic signature. Stamped signatures are not acceptable. Providers should not add late 
signatures to the medical record, (beyond the short delay that occurs during the transcription process) but 
instead should make use of the signature authentication process. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, 3.3.2.4. 
 
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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
The rules say that if a Group 3 PWC is provided and if criteria (IV)(A)  (IV)(D) are not met, it will be denied 
as not reasonable and necessary. 
I. A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple 
Power Options (K0861, K0862, K0863, K0864) is covered if:  
A. The Group 3 criteria IV(A) and IV(B) are met; and 
B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria 
III[A] and III[B]) (respectively) are met. 
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or 
(V)(B) is not met, it will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Determination (LCD) Power Mobility Devices L3789. 
 
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 for crutch substitutes (E0118) there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these 
products. This information can be found on the DME MAC website Medical Director Article dated May 4, 
2017. 
 
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 payment for inpatient hospital services in made of the basis of a DRG (diagnosis related group). 
Hospitals must provide proper information about the patient (i.e., age, sex, discharge status, principal and 
secondary diagnoses, and procedures) in order for the correct DRG to be assigned. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 3, Section 20.2.1. 
 
The rule say that the circumstances of inpatient admission always govern the selection of principal diagnosis. 
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition 
established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for 
care. For reporting purposes the definition for other diagnoses is interpreted as additional conditions that 
affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; 
or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b 
defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or 
that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which 
have no bearing on the current hospital stay are to be excluded. You can find this information in the 
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines 
for Coding and Reporting, Sections II and III. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays for outpatient rehabilitation therapy services only when they are provided by 
those trained specifically in physical therapy, occupational therapy or speech-language pathology. This means 
that the services of massage therapists may not be billed as covered therapy services. You can find these rules 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare 
Benefit Policy Manual, Chapter 15, Section 230.5. 
 
The rules say that Medicare plans may not offer a massage therapy benefit. 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 30.4. 
 
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 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 certain skin substitute products are separately paid, based on their standard SI/APC 
assignment, only when billed with specified skin substitute application procedure codes. If one of the specified 
application procedure codes is not present on the same date of service as the skin substitute, the skin substitute 
product is packaged. Effective 1/1/2014 (v15.0), the submission of certain skin substitute application 
procedures requires the reporting of a skin substitute product for the same day. Certain skin substitute 
application procedures and skin substitute products are divided into two lists based on high or low cost. Claims 
containing a high cost skin substitute application procedure without any of the high cost skin substitute product 
codes, and conversely any low cost skin substitute application procedure without a low cost skin substitute 
product code for the same day, are returned to the provider. You can find this information in the Integrated 
OCE (IOCE) CMS Specifications V22.2 Section 5.13 Skin Substitute Editing and Processing. 
 
The rules say that effective for claims with dates of service July 1, 2007 and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE 
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the  
 Web at the following address 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
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 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare National Coverage Determination for Next Generation Sequencing, 90.2. 
 
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 Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 95 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 plans may specify brands and manufacturers as preferred and charge lower cost-sharing for 
the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the 
enrollee retains access to all medically necessary items (including non-preferred brands). You can find this 
information in the Medicare Managed Care Manual Chapter 4, Section 10.12.2.  
 
The rules say that for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiarys medical 
documentation and confirm that Medicare coverage criteria have been met. You can find this information in the 
Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 100-08, Medicare Program 
Integrity Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this information at 42 Code of Federal Regulations (CFR), Section 424.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that diabetic testing supplies obtained through the pharmacy are limited to Ascensia branded 
products and LifeScan branded products. You can find that information on page 67 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 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 Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 pages 101 and 167 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 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 page 13 to 14 of the Plan's 
2021 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 Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
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 Plan 
contract also says that you have $150 allowance towards your cost for a membership in a qualified health club 
or fitness facility. You can find this information on page 78 to 79 of the Plan's 2021 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 a Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 6, Section 60.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that you can get your care from an out-of-network provider; however, in most cases that 
provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who 
is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before 
receiving services to confirm that they are eligible to participate in Medicare. You can find this information on 
page 45 of the Plan's 2021 Evidence of Coverage.