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 evidence is still limited due to the overall high risk of bias in previous trials and great 
variability between studies regarding the number of injections (generally 1 to 4), the interval between 
injections, preparation of the platelet rich plasma (PRP), and volume injected. Furthermore, the typical length 
of follow up was only one year or less. There is also uncertainty regarding whether individuals with less severe 
osteoarthritis (OA) may benefit more from this intervention compared with individuals with more advanced 
structural damage. Additionally, it is unclear whether LR-PRP or LP-PRP should be utilized, though the latter 
appears to have an advantage. Larger controlled studies comparing PRP with placebo and alternatives other 
than HA are needed to determine the efficacy of PRP for knee OA. Further studies are also needed to determine 
the optimal protocol for delivering PRP. At present, the evidence is insufficient to determine the effects of PRP 
on health outcomes for OA. You can find this information in the Local Coverage Determination (LCD) 
L39071: Platelet Rich Plasma. 
 
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 the following is considered not medically reasonable and necessary: 
 Genetic testing where either analytical validity, clinical validity, or clinical utility has not been 
established. 
 Germline testing may be performed once in a lifetime per beneficiary.  
o Any laboratory test that investigates the same germline genetic content, for the same genetic 
information, that has already been tested in the same Medicare beneficiary is not medically 
reasonable and necessary as it is duplicative. The germline sequence of an individual does not 
change over time, and therefore repeat testing of the same germline content for the same genetic 
information does not provide new clinical information. 
You can find this rule in Local Coverage Determination (LCD) Pharmacogenomics Testing L39063. 
 
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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
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 several Healthcare Common Procedural Coding System (HCPCS) modifiers are used to 
signify a specific line item is either not covered or not payable by Medicare, for many different reasons. The 
chart immediately below lists those modifiers, many more commonly used on professional claims, for services 
not covered or not payable by Medicare. Modifiers that are not payable are -A1 through -A9, -GY, -GZ, -H9, -
HA through -HZ, -SA through -SE, -SH, -SJ, -SK, -SL, -ST, -SU, -SV, -SY, -TD through -TR, -TT through -
TW, -U1 through -U9, -UA through -UD, and -UF through -UK. Modifiers not payable on professional claims 
are also not payable on institutional claims and will be denied if submitted on such claims. Providers are liable 
for these denials, UNLESS a specific modifier (see second table in this section) or indicator on the claim (i.e., 
occurrence code 32) specifically assigns liability to the beneficiary. You can find this rule in the Centers for 
Medicare & Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 1, Section 60.4.2. 
 
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 a cervical traction device (E0849) is covered only if both of the following criteria are met: 
 
1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 
2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the 
beneficiary tolerated the selected device. 
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. You can find 
this rule in the Local Coverage Determination (LCD) - Cervical Traction Devices (L33823). 
 
The rules say that cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 
and 2 above and either criterion A, B or C below has been met: 
 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received treatment 
for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a 
chin halter is unable to be utilized; or, 
c. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
 
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will 
be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - 
Cervical Traction Devices (L33823). 
 
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 therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for 
the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is 
not separately payable. If performed to facilitate the infusion or injection or hydration, the following services 
and items are included and are not separately billable: 
1. Use of local anesthesia; 
2. IV start; 
3. Access to indwelling IV, subcutaneous catheter or port; 
4. Flush at conclusion of infusion; and 
5. Standard tubing, syringes and supplies. 
Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy 
injection and infusion service. 
 
Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for 
the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the 
same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is 
made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified 
the need for sutures and confirmed allergy and immunization status. 
 
You can find this information in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.5 and 40.1.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.
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 specific 
dental procedures included in a dental benefits chart. Oral surgery is not listed as a covered dental benefit. You 
can find this information on pages 52-53 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 plans can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
 
You can find this rule at 42 CFR Section 422.113(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 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 37 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 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 the LCD revised and published on 07/13/2017 to add references received with a 
reconsideration request for CxBladder coverage. After review of the submitted literature, it has been 
determined that non-coverage of CxBladder will remain.  No substantial changes are being made to the LCD at 
this time.  
 
LCD revised and published on 10/04/2018 to update the policy in response to inquiry and reconsideration 
requests; all literature reviewed and added to policy. Non-coverage reaffirmed for CPT codes 0012M and 
0013M for CxBladder. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35396: Biomarkers for 
Oncology. 
 
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 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 says that while you can get care form an out-of-network provider, the 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 go to 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 34 of the Plans 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 pays for care in a skilled nursing facility (SNF) when all of the following four 
factors are met: 
 
1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services on a daily basis; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patients illness or injury or the services 
must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from 
getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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 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 & 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 limits coverage of blood glucose monitors and test strips to specified brands. You can find this 
information on pages 51 to 52 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 a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of 
stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need 
medical care. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
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 Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
 
Section 1861(s)(2) of the Social Security Act extends coverage to oral anti-emetic drugs that are used as full  
replacement for intravenous dosage forms of a cancer regimen under the following conditions: 
 Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for  
use as anti-emetics; 
 The oral anti-emetic must either be administered by the treating physician or in accordance with a  
written order from the physician as part of a cancer chemotherapy regimen; 
 Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated  
within 2 hours of the administration of the chemotherapeutic agent and may be continued for a  
period not to exceed 48 hours from that time; 
 The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the  
intravenous anti-emetic drugs that would have otherwise been administered at the time of the  
chemotherapy treatment. 
Only drugs pursuant to a physicians order at the time of the chemotherapy treatment qualify for this benefit.  
The dispensed number of dosage units may not exceed a loading dose administered within two hours of the  
treatment, plus a supply of additional dosage units not to exceed 48 hours of therapy. 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, Sections 50, 50.2, 50.5, and 110.3. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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.