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 generally, the place of service (POS) code is used to reflect the actual setting where the 
beneficiary receives the face-to-face service. When services are furnished in a mobile unit, they are often 
provided to serve an entity for which another POS code exists. For example, a mobile unit may be sent to a 
physicians office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS 
code already exists, providers should use the POS code for that entity. However, if the mobile unit is not 
serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit 
POS code 15. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5. 
 
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.
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 Percutaneous Vertebral Augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients with both the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  
L5) by recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging 
(MRI) or bone-scan/single photon emission computed tomography (SPECT)/computed tomography 
(CT) uptake) 
b. Symptomatic (ONE):  
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain 
score  8) 
ii. Non-hospitalized with moderate-to-severe pain (NRS or VAS 5) despite optimal non-surgical 
management (NSM) (ONE):  
1. Worsening pain 
2. Stable-to-improved pain (but NRS or VAS still 5) (with  2 of the following):  
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17) 
You can find this information in the Local Coverage Determination (LCD) for Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 in Chapter 4 on pages 72 to 74 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 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 beginning January 1, 2008, ambulatory surgical centers (ASCs) no longer are required to 
include the SG modifier on facility claims in Medicare. The contractors shall assign TOS code F to codes 
billed by specialty 49 for Place of Service 24. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
14, Section 50. 
 
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 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 also say that Renal dialysis facilities must bill all lab tests provided for the treatment of end-stage 
renal disease (ESRD). This is true whether the tests were provided directly or under arrangements with an 
independent lab. ESRD facilities should only bill for lab tests related to the treatment of ESRD or other lab 
tests performed by the dialysis facility. You can find this in the Centers for Medicare and Medicaid Service, 
Internet-Only Manual, Publication Number 100-04, Medicare Claims Processing Manual, Chapter 8, Section 
60.1. 
 
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 high frequency chest wall oscillation devices (HFCWO) (E0483) are covered for 
beneficiaries who meet: 
A. Criterion 1, 2, or 3, and 
B. Criterion 4 
1. There is a diagnosis of cystic fibrosis. 
2. There is a diagnosis of bronchiectasis which has been confirmed by a high resolution, spiral, or 
standard CT scan and which is characterized by: 
a. Daily productive cough for at least 6 continuous months; or 
b. Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. 
Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence 
of a confirmed diagnosis of bronchiectasis do not meet this criterion. 
3. The beneficiary has one of the following neuromuscular disease diagnoses: 
a. Post-polio 
b. Acid maltase deficiency 
c. Anterior horn cell diseases 
d. Multiple sclerosis 
e. Quadriplegia 
f. Hereditary muscular dystrophy 
g. Myotonic disorders 
h. Other myopathies 
i. Paralysis of the diaphragm 
4. There must be well-documented failure of standard treatments to adequately mobilize retained 
secretions. 
 
You can find these rules in Local Coverage Determination (LCD) High Frequency Chest Wall Oscillation 
Devices (L33785). 
 
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 standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all 
of the following criteria (1-3) are met: 
 
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
 
These rules are found in Medicare Local Coverage Determination (LCD): Walkers (L33791). 
 
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 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: 
-either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
-not been previously tested with the same test using NGS for the same cancer genetic content, and 
-decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
You can find this information in National Coverage Determination (NCD): Next Generation Sequencing (NGS) 
(90.2). 
 
All the following must be present for coverage eligibility: 
 
    1. As per NCD 90.2, this test is reasonable and necessary when: 
        -the patient has either: 
            -Recurrent cancer 
            -Relapsed cancer 
            -Refractory cancer 
            -Metastatic cancer 
            -Advanced cancer (stages III or IV) 
        -AND has not been previously tested by the same test for the same genetic content 
        -AND is seeking further treatment 
    2. The test has satisfactorily completed a technical assessment (TA) by MolDX for the stated indications of 
the test 
    3. The assay performed includes at least the minimum genes and genomic positions required for the 
identification of clinically relevant FDA-approved therapies with a companion diagnostic biomarker as well as 
other biomarkers known to be necessary for clinical decision making for its intended use that can be reasonably 
detected by the test. Because these genes and variants will change as the literature and drug indications evolve, 
they are listed separately in associated documents such as the MolDX TA forms. 
 
You can find this information in Local Coverage Determination (LCD): MolDX: Next-Generation Sequencing 
for Solid Tumors (L38121). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $175 copayment for for surgery performed in an ambulatory surgical 
center (ASC) or in an outpatient hospital facility. You can find this information on page(s) 70 to 71 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 state that equipment which the beneficiary owns or is a capped rental item may be replaced in cases 
of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster. A 
physicians order and/or new certificate of medical necessity (CMN), when required, is needed to reaffirm the 
medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over 
time and a specific event cannot be identified. Medicare contractors may determine the reasonable useful 
lifetime of equipment, but in no case can it be less than 5 years. Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. You can find these rules in Medicare Benefit Policy Manual 
Chapter 15, 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. 
 
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. Covered dental services are 
listed on pages 58-60 and 105-125 of the Plans 2023 Evidence of Coverage (EOC). Any service not listed is 
not covered.
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 also say interpret the phrase new patient to mean a patient who has not received any professional 
services, i.e., evaluation and management (E/M) service or other face-to-face service (e.g., surgical procedure) 
from the physician or physician group practice (same physician specialty) within the previous 3 years. For 
example, if a professional component of a previous procedure is billed in a 3-year time period, e.g., a lab 
interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this 
patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or 
electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient 
does not affect the designation of a new patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 12, Section 30.6.7. 
 
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 spinal orthosis (such as L0637) is covered when it is ordered for one of the following 
indications: 
1. To reduce pain by restricting mobility of the trunk; or 
2. To facilitate healing following an injury to the spine or related soft tissues; or 
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or 
4. To otherwise support weak spinal muscles and/or a deformed spine. 
 
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically 
necessary. You can find these rules in Local Coverage Determination (LCD) Spinal Orthoses: TLSO and LSO 
(L33790). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $40 copayment for in-network basic radiological services provided in a 
specialists office. You can find this information on page(s) 63 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 the global surgery package of procedures with a global period of 10 or 90 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the surgery 
because of complications which do not require additional trips to the operating room, follow-up visits during 
the postoperative period of the surgery that are related to recovery from the surgery, among other related 
services. In order to report an unrelated evaluation and management (EM) service by same physician during a 
postoperative period, modifier -24 must be used. Services submitted with the -24 modifier must be sufficiently 
documented to establish that the visit was unrelated to the surgery. Not included in the global surgery payment 
are clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment 
for complications. These services should be billed with modifier -79. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, 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.