Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 48 one-way trips per year. You can find this information on pages 111-112 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 oxygen is coverable when medically necessary for patients with acute or chronic conditions, 
short- or long- term, when the patient exhibits hypoxemia. Patients exhibiting hypoxemia are defined using the 
clinical criteria below.  
 
1. Arterial PO2 (partial pressure of oxygen) at or below 55 mm Hg or arterial O2 (oxygen) saturation at or 
below 88% on room air, at rest; 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for patients who have hypoxia symptoms during sleep; 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when 
medically reasonable and necessary for patients who do not have a non-covered indication. 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 240.2. 
 
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 state that Effective for services furnished on or after February 5, 2015, Medicare covers a lung cancer 
screening counseling and shared decision-making visit, and for appropriate beneficiaries, annual screening for 
lung cancer with low dose computed tomography (LDCT) if all the eligibility requirements listed in the 
national coverage determination (NCD) are met. Beneficiaries must meet all of the following eligibility criteria: 
Age 50 - 77 years; Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 
20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker 
or one who has quit smoking within the last 15 years; and receive an order for lung cancer screening with 
LDCT.  You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 220. 
 
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 type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An 
Excludes1 note indicates that the code excluded should never be used at the same time as the code above the 
Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form 
versus an acquired form of the same condition. You can find this information in the International Classification 
of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting, 
FY 2022. 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) (L35025). 
 
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 coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 
or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - 
Effective January 1, 2020.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that definitive drug testing is indicated when: 
 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. 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. 
 
Drugs, or drug classes for which testing is performed, should reflect only those likely to be present, based on 
the patient's medical history, current clinical presentation, and illicit drugs that are in common use. Drugs for 
which specimens are being tested must be indicated by the referring provider in a written order. You can find 
this rule in the Local Coverage Determination (LCD) - Drug Testing (L34645) - Effective October 1, 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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. You can find this rule in the Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules state that a type 1 Excludes note for a diagnosis code is a pure excludes note. It means NOT 
CODED HERE! An Excludes1 note indicates that the code excluded should never be used at the same time as 
the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a 
congenital form versus an acquired form of the same condition. You can find this information in the ICD-10-
CM Official Guidelines for Coding and Reporting, Section I. Conventions, general coding guidelines and 
chapter specific guidelines. 
 
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 low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
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 health 
Plan contract says that covered routine vision care includes an annual routine eye exam, eye refractions during 
a routine exam, eyeglass lenses and eyeglass frames or contact lenses wen performed by a Pan routine vision 
care provider. You can find this information on pages 86 of the Plan's 2023 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 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 bariatric surgery procedures are performed to treat comorbid conditions associated with 
morbid obesity when certain criteria are met. Treatments for obesity alone remain non-covered. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-03, 
Medicare National Coverage Determinations (NCD) Manual, Section 100.1. 
 
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 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 A/B MACs (B) must pay for a physicians weekly treatment management services under 
code 77427. Billing entities must indicate on each claim the number of fractions for which payment is sought. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Pub 100-04, 
Medicare Claims Processing Manual, Chapter 13, Section 70.1. 
 
The rules say that a weekly unit of treatment management is equal to five fractions or treatment sessions. A 
week for the purpose of making payments under these codes is comprised of five fractions regardless of the 
actual time period in which the services are furnished. It is not necessary that the radiation therapist personally 
examine the patient during each fraction for the weekly treatment management code to be payable. Multiple 
fractions representing two or more treatment sessions furnished on the same day may be counted as long as 
there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on 
different days. If, at the final billing of the treatment course, there are three or four fractions beyond a multiple 
of five, those three or four fractions are paid for as a week. If there are one or two fractions beyond a multiple 
of five, payment for these services is considered as having been made through prior payments. You can find 
this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Pub 100-04, Medicare 
Claims Processing Manual, Chapter 13, Section 70.1. 
 
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 Medicare payment may be made for services furnished to individuals or groups of 
individuals who are in the custody of the police or other penal authorities or in the custody of a government 
agency under a penal statute only if the following conditions are met: (1) State or local law requires those 
individuals or groups of individuals to repay the cost of medical services they receive while in custody. (2) The 
State or local government entity enforces the requirement to pay by billing all such individuals, whether or not 
covered by Medicare or any other health insurance, and by pursuing the collection of the amounts they owe in 
the same way and with the same vigor that it pursues the collection of other debts.  
 
Providers that render services or items to a prisoner or patient in a jurisdiction that meets these conditions shall 
append modifier QJ on all lines with a line item date of service during the incarceration period. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 1, Section 10.4. 
 
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 an expandable controller is capable of accommodating one or more of the following 
additional functions: 
 
-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
-Non-proportional input devices (e.g., sip and puff, head array, etc.) 
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
 
-A separate display (i.e., for alternate control devices) 
-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control) 
-An attendant control 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that code E2311 describes an electronic component that allows the patient to control two or more 
of the following motors from a single interface; e.g. proportional joystick, touchpad or nonproportional 
interface: 
 
-Power tilt 
-Power recline, with or without shear reduction 
-Combination power tilt and recline, with or without shear reduction 
-Power leg elevation with or without articulation, power center mount elevating foot platform with or without 
articulating properties 
 You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
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. 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35025 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A56853.  
 
The rules say that the Physician Fee Schedule Status Indicator T 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.