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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
Total knee replacement surgery will be considered medically necessary when one or more of the following 
criteria are met: 
1. Failure of a previous osteotomy; or 
2. Distal femur fracture; or 
3. Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or 
4. Failure of previous unicompartmental knee replacement; or 
5. Avascular necrosis of the knee; or 
6. Proximal tibia fracture; or 
7. Advanced joint disease demonstrated by: 
a. Radiographic supported evidence or when conventional radiography is not adequate, magnetic 
resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, 
periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); and 
b. Pain or functional disability from injury due to trauma or arthritis of the joint; and 
c. Unsuccessful history of appropriate conservative therapy (non-surgical medical management) 
that is clearly addressed in the pre procedure medical record. Non-surgical medical management 
is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as 
clinically appropriate for the patients current episode of care typically include one or more of 
the following: anti-inflammatory medications, analgesics, flexibility and muscle strengthening exercises, supervised physical therapy [Activities of daily living (ADLs) diminished despite 
completing a plan of care], activity restrictions as is reasonable, assistive device use, weight 
reduction as appropriate, therapeutic injections into the knee as appropriate. 
Local Coverage Determination (LCD): Major Joint Replacement (Hip and Knee) (L33618). 
 
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 the test panel is a single test with multiple components and is characterized by a single unit 
of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact 
that the test reports multiple individual pathogens and/or targets. If additional organisms are not included in a 
panel, testing for those organisms separately may be reasonable and necessary when ordered in addition to the 
panel and supported by documentation in the medical record. You can find this rule in Local Coverage Article 
Billing and Coding Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen 
Identification Testing A58726. 
 
The rules say that a bacterial urine culture is a laboratory procedure performed on a urine specimen to establish 
the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a 
urine culture. A urine culture may also be used as part of the evaluation and management of another related 
condition. You can find this rule in National Coverage Determination (NCD) Urine Culture, Bacterial 190.12. 
 
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 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 72 one-way trips per benefit year. You can find this information on pages 119-120 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 that only the Progensa PCA3 and ConfirmMDx tests have met Medicare coverage criteria.
You can find this rule at Local Coverage Article (LCA) A58718: Billing and Coding: MolDX: Molecular
Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (eff. August 8, 2022, to November 1,
2023).

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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(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 says that the only covered chiropractic service is manual manipulation of the spine to correct 
a subluxation. Other services performed by a chiropractor are not covered. You can find this information on 
page 49 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 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 does not include 
coverage for the dental service code D4910. You can find this information in Chapter 4 on pages 58-59 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 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 
coverage for specific dental items/services stated in the Plans contract. You can find this information on pages  
80-84 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 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 a total of 12 one-way non-emergency ground transportation trips within our service area every year. 
This benefit is available to help you obtain medically necessary care and services. You can find this 
information on page 116 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 state that in the case of tests for infectious agents, methodologies include detection by immunofluorescence, immunoassay, or nucleic acid probe techniques. A single laboratory procedure shall be reported as one unit of service whether it generates one or multiple results. When multiple procedures, multiple methodologies, or multiple kits are medically necessary and used to perform a test for multiple infectious agents, the units of service reported for codes that identify multiple infectious agents equals the number of different procedures, methodologies, or kits used to perform the test. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative (NCCI) Manual, Chapter 10, Section M(15).

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 
preventive and comprehensive dental services along with specific dental services that are listed on the dental 
benefit chart. Dentures are not covered by the Plan's dental benefits. You can find this information on pages 80 
to 83 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 payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
 
1. be provided under an individualized treatment or diagnostic plan; 
 
2. reasonably be expected to improve the patients condition, or for the purpose of diagnosis; and 
 
3. be supervised and evaluated by a physician.   
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services 
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 
1862(a)(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 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 24 one-way trips. You can find this information on pages 70 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 state that for claims submitted on or after March 1, 2023 suppliers must add the KX modifier to claim 
lines billed for the external infusion pump, drugs and supplies for dates of service on or after January 1, 2023, 
only if all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section 
in the related LCD have been met. Evidence supporting the use of the KX modifier must be retained in the 
suppliers files and available to the DME MAC upon request. The KX modifier requirement will continue to be 
required for HCPCS E0784 and J1817 for any date of service billed, if applicable. 
 
Claim lines billed for the above services without a KX, GA, or GZ modifier will be rejected as missing 
information for claims submitted on or after March 1, 2023 for all codes. You can find this rule in the Local 
Coverage Article for External Infusion Pumps - Policy Article, A52507. 
 
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 CMS has not issued specific coverage criteria in the form of an LCD (Local Coverage 
Determination) or NCD (National Coverage Determination) for this particular item or service. However, per 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), Medicare does not pay for any 
items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member. The determination of medical necessity must be 
tailored to the individual patient and their unique clinical scenario. CMS considers services to be medically 
reasonable and necessary if they are:  
  
- Safe and effective; 
- Not mainly for the convenience of the patient or the physician; 
- Not experimental or investigational; and 
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of 
whether it is: 
 - Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
patient's condition or to improve the function of a malformed body member; 
 - Furnished in a setting appropriate to the patient's medical needs and condition; 
 - Ordered and furnished by qualified personnel; 
 - One that meets, but does not exceed, the patient's medical need; and 
 - At least as beneficial as an existing and available medically appropriate alternative. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Program Integrity Manual, Chapter 13, Section 13.5.4. 
 
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 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 
preventive and comprehensive dental services. Prescription drugs or pre-medications, whether dispensed or 
prescribed are not covered by the Plan's dental benefits. You can find this information on page 72 and pages 77 
to 78 of the Plans 2023 Evidence of Coverage (EOC).