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. 
 
Medicare guidance says the following data elements are required to submit a claim under home health 
Prospective Payment System (PPS). For billing of home health claims not under an HH plan of care (not under 
HH PPS), see Section 90. Home health services under a plan of care are paid based on a 30-day period of care. 
Home health agencies (HHAs) submit an Notice of Admission (NOA) at the beginning of an admission and 
then submit one claim for each 30-day period of care. Claims submitted before an NOA has been received for 
the beneficiary will be returned to the provider. 
 
Type of Bill 
Required - This 4-digit alphanumeric code gives two pieces of information. The first three digits indicate 
the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. 
The types of bill accepted for HH PPS claims are: 
032x - Home Health Services under a Plan of Treatment 
4th Digit  Definition 
 
7 - Replacement of Prior Claim - HHAs use to correct a previously submitted bill. Apply this code for 
the corrected or new bill. These adjustment claims must be accepted at any point within the timely 
filing period after the payment of the original claim. 
 
8 - Void/Cancel of a Prior Claim - HHAs use this code to indicate this bill is an exact duplicate of an 
incorrect bill previously submitted. A replacement claim must be submitted for the period of care to be 
paid. 
 
9 - Final Claim for an HH PPS Period  This code indicates an HH original bill to be processed 
following the submission of an HH PPS Notice of Admission (Type of Bill (TOB) 032A) 
 HHAs must submit HH PPS claims with the 4th digit of 9. These claims may be adjusted with code 
7 or cancelled with code 8. A/B MACs (HHH) do not accept late charge bills, submitted with code 
5, on HH PPS claims. To add services within the period of a paid HH claim, the HHA must submit an 
adjustment. 
 
You can find this information in the Medicare Claims Processing Manual Chapter 10 - Home Health Agency 
Billing, 40.2 - HH PPS Claims. 
 
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 a spinal electrical osteogenesis stimulator (E0748) is covered only if any of the following 
criteria are met: 
1. Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
2. Following a multilevel spinal fusion surgery (see Appendices section), or 
3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at 
the same site. 
A spinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria 
above are met. You can find this rule at Local Coverage Determination (LCD) L33796: Osteogenesis 
Stimulators (eff. 7/2/23). 
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 considers genetic testing medically necessary to establish a molecular diagnosis of 
an inheritable disease when all of the following criteria are met: 
 The beneficiary must display clinical features of an associated disease, but noting that coverage of 
molecular testing for carrier status or family studies is considered screening and is statutorily excluded 
from coverage; and 
 The result of the test will directly impact the treatment being delivered to the beneficiary; and 
 A definitive diagnosis remains uncertain after history, physical examination, pedigree analysis, genetic 
counseling, and completion of conventional diagnostic studies. 
You can find this rule at Local Coverage Determination (LCD) L35062: Biomarkers Overview (eff. 12/12/21). 
 
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. 
PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the 
following: 
1. Inclusion criteria (ALL are required):  
a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression 
Fracture (VCF) (T1  L5), based on symptom onset, and documented by advanced imaging 
(bone marrow edema on Magnetic Resonance Imaging (MRI) or bone-scan/ Single-photon 
emission computed tomography (SPECT)/computed tomography (CT) uptake) (1-3,10,25,27) 
b. Symptomatic (ONE):  
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score greater than or equal to 8) (4-7) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) 
despite optimal non-surgical management (NSM) (10) (ONE):  
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still greater than or equal to 5) (with 
greater than or equal to 2 of the following):  
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (10) (Both)   
i. All patients presenting with VCF should be referred for evaluation of bone mineral 
density (BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (2,5,8-10) (Can have NONE of the following):   
a. Absolute contraindication  
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication  
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
You can find this rule in the Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 20% coinsurance for durable medical equipment. You can find this 
information on page 62 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 the following data elements are required to submit a claim under home health Prospective 
Payment System (PPS). For billing of home health claims not under a home health (HH) plan of care (not 
under HH PPS), see Section 90. Home health services under a plan of care are paid based on a 60-day episode 
of care (before January 1, 2020, or a 30-day period of care (on or after January 1, 2020). Payment for this 
episode or period will usually be made in two parts. After a RAP has been paid and an episode or period has 
been completed, or the patient has been discharged, the HHA submits a claim to receive the balance of 
payment due. For episodes beginning on or after July 1, 2013, HHAs must report where home health services 
were provided. The following codes are used for this reporting: 
 
Q5001: Hospice or home health care provided in patients home/residence 
Q5002: Hospice or home health care provided in assisted living facility 
Q5009: Hospice or home health care provided in place not otherwise specified 
 
The location where services were provided must always be reported along with the first visit reported on the 
claim. In addition to reporting a visit line using the G codes as described above, HHAs must report an  
additional line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, 
Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). If the location where services were 
provided changes during the episode, the new location should be reported with an additional line corresponding 
to the first visit provided in the new location. You can find the guidance in the Medicare Claims Processing 
Manual Chapter 10 - Home Health Agency Billing 40.2. 
 
Medicare guidance says the A/B Medicare Administrative Contractors (MACs) (A) must provide a listing of 
the required data elements, including a brief explanation to providers and suppliers.  A/B MACs (A) must educate providers regarding the distinction between submissions which are not 
considered claims, but which are returned to provider (RTP) and submissions which are accepted by Medicare 
as claims for processing but are not paid. Claims may be accepted as filed by Medicare systems but may be 
rejected or denied. Unlike RTPs, rejections and denials are reflected on Remittance Advices (RAs). Denials are 
subject to appeal, since a denial is a payment determination. Rejections may be corrected and resubmitted. You 
can find the guidance in the Medicare Claims Processing Manual Chapter 1 - General Billing Requirements 
Section 70.2.3.2. 
 
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 a pneumatic compression device (PCD) coded as E0652 is not covered for the treatment of 
lymphedema of the extremities alone. A PCD coded as E0652, is covered for the treatment of lymphedema 
extending onto the chest, trunk and/or abdomen when all of the following are met: 
1. The beneficiary has lymphedema of an extremity as defined above 
  
2. The coverage criteria for an E0650 or E0651 are met 
  
3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits 
of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve 
with a four-week trial. 
  
The rules say that the only time that a segmented, calibrated gradient pneumatic compression device 
(Healthcare Common Procedure Coding System code E0652) would be covered is when the individual has 
unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a 
nonsegmented device in conjunction with a segmented appliance or a segmented compression device without 
manual control of pressure in each chamber. 
  
The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment with and 
E0650 or E0651 is required for coverage of E0652.  
 
You can find this information in Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829) - 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 beginning January 1, 2022, home health agencies (HHAs) will no longer submit Requests for 
Anticipated Payment (RAPs). Instead, for each admission to home health the HHA notifies Medicare systems 
via submission of a Notice of Admission (NOA). The NOA is a one-time submission to establish that the 
beneficiary is under a home health period of care and trigger home health consolidated billing edits. The NOA 
covers contiguous 30-day periods of care until the individuals is discharged from Medicare home health 
services.  
 
All HHAs must submit an NOA to their Medicare contractor within 5 calendar days from the start of care date 
to establish that the beneficiary is under a Medicare home health period of care and also to trigger home health 
consolidated billing edits. In instances where an NOA is not timely-filed, Medicare shall reduce the payment 
for a period of care, including outlier payments, by the number of days from the home health admission date 
until the date the NOA is submitted to, and accepted by, the contractor, divided by 30. This reduction shall be a 
provider liability, and the provider shall not bill the beneficiary for it. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 7, Section 10.4. 
 
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 state that codes for inserts or modifications (A5503, A5504, A5505, A5506, A5507, A5508, A5510, 
A5512, A5513, A5514) may only be used for items related to diabetic shoes (A5500, A5501). They must not 
be used for items related to footwear coded with codes L3215, L3216, L3217, L3219, L3221, L3222, L3224, 
L3225, L3230, L3250, L3251, L3252, L3253. Inserts and modifications used with L-coded footwear must be 
coded using L codes. You can find this in the Local Coverage Article (LCA): Therapeutic Shoes for Persons 
with Diabetes - Policy Article (A52501). 
 
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 $30 copayment for outpatient X-ray. You can find this information on 
page 78 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 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 $250 copayment per day for days 1-5 of each inpatient hospital stay. 
Enrollees then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. This copayment is applied for each visit. You can find this 
information on pages 57-60 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 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).  
 
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 there is a $1,000 deductible which applies to certain items and services. The Plan 
deductible applies to in-network outpatient surgery. You can find this information on pages 38-39 of the Plan's 
2023 Evidence of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay a $295 copayment after meeting the deductible for in-
network outpatient surgery provided at an outpatient hospital. You can find this information on pages 87-89 of 
the Plans 2023 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 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 50% coinsurance for outpatient mental health care. You can find this 
information on page 69 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 state that current molecular diagnostic tests that identify individuals with upper gastrointestinal 
metaplasia, dysplasia, and neoplasia are non-covered by this contractor. 
We expect these types of tests to meet the following criteria: 
 The beneficiary is being actively managed for chronic gastroesophageal reflex disease (GERD) and/or 
non-dysplastic Barretts esophagus (NDBE); and 
 They also have at least three additional risk factors for Barretts esophagus (BE) as described in 
nationally recognized guidelines. 
 The beneficiary has not been previously diagnosed with dysplasia or esophageal carcinoma; and 
 The beneficiary is tested no more than recommended by established national or society guidelines; and 
 The test identifies patients with dysplastic disease that may benefit from endoscopic treatment or 
surveillance, or patients with non-dysplastic disease who may benefit from surveillance; and 
 The test results will be used in determining treatment or management of the beneficiary. 
 The beneficiary is within the population for which the test was developed and validated. The laboratory 
providing the test is responsible for clearly indicating to treating clinicians the population and indication 
for test use. 
 The test demonstrates analytical validity (AV) including an analytical and clinical validation for any 
given measured analytes and has demonstrated equivalence or superiority for sensitivity or specificity 
of detecting dysplasia to other already accepted methods for the same intended use measuring the same 
or comparable analytes. 
 Clinical validity (CV) of any analyte measured must be demonstrated in the published peer-reviewed 
literature, establishing a clear and significant biological/molecular basis for stratifying patients and 
subsequently selecting (either positively or negatively) their clinical management decision within a 
clearly defined population. 
 The test successfully completes a Technical Assessment that will ensure that criteria set in this policy 
are met to establish the test as Reasonable and Necessary. You can find this rule at the Medicare Local Coverage Determination (LCD) L39356: MolDX: Molecular 
Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia. 
 
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.