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 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 20% coinsurance for Part B drugs. You can find this information on pages 
4-27 and 4-28 of the Plan's 2021 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 50 one-way routine transportation trips. You can find this information on page 82 of the Plans 2022 
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. 
 
Medicare may cover the use of a Food and Drug Administration (FDA)-approved drug or biological if it is safe 
and effective and otherwise reasonable and necessary for the patient. FDA-approved drugs used for indications 
other than what is indicated on the official label may be covered if the use is determined to be medically 
accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted 
standards of medical practice. 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 50.4.1 and 
50.4.2. 
 
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 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 KX modifier (Requirements specified in the medical policy have been met) is now a 
multipurpose informational modifier and will also be used identify services for transgender, ambiguous 
genitalia, and hermaphrodite beneficiaries in addition to its other existing uses. Physicians and non-physician 
practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of 
transgender, ambiguous genitalia, and hermaphrodite beneficiaries. You can find this rule in the Centers for 
Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 32, Section 240. 
 
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 $150 copayment for outpatient surgery at an outpatient hospital. You 
can find this information on page 88 of the Plan's 2021 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 PVA (percutaneous vertebroplasty (PVP) or 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 VCF (T1  L5) by recent (within 30 days) 
advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/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) 
c. Continuum of care
 
(BOTH): 
1.  
i. All patients presenting with VCF should be referred for evaluation of 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. 
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). 
 
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 $750 deductible which applies to certain items and services. The Plan 
deductible applies to an out of network office visit. You can find this information on pages 56 of the Plan's 
2021 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 417.414. 
 
The rules state that polyethylene-glycol (PEG) hydrogel is covered once in patients with clinically localized 
prostate cancer with both of the following:  
- Inclusion criteria including all of the following: 
~ Low or Favorable Intermediate Prostate Cancer Risk Group 
~ Dose escalated (76 or greater Gy) conventional fractionation (1.8-2 Gy fractions) or moderate 
hypofractionation (HFX) (2.4-3.4 Gy fractions) IG-IMRT planned 
~ Eastern Cooperative Oncology Group (ECOG) performance status 1 or less 
~ Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side 
effects due to at least one of the following: 
- Anatomic geometry precluding ideal rectal constraints  
- Conventional fractionation 
- Moderate HPX (dose constraints not yet standardized; employ those used in the 
supporting phase III trials) 
- Medication usage (e.g., anticoagulants) 
- Comorbid conditions (e.g., increased age, Hx MI or CHF) 
- No Exclusion criteria including all of the following: 
~ Less than 5 year life-expectancy and asymptomatic 
~ Prior prostate cancer treatment (surgery or RT) 
~ Active bleeding disorder or clinically significant coagulopathy 
~ Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, 
anorectal IBD) 
~ Prostate volume greater than 80 cc 
 
Prostate rectal spacers are various materials or devices placed between the prostate and anterior wall of the 
rectum for use in men receiving radiation therapy for prostate cancer. The anterior wall of the rectum is 
considered a major dose-limiting factor in radiation therapy of prostate cancer. Physical separation is proposed 
to allow reduced toxicity and treatment intensification. You can find these rules in Local Coverage 
Determination (LCD) Prostate Rectal Spacers (L37485). 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112. 
 
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the 
services are obtained in or out of the plans network. This rule applies whether or not there is prior 
authorization for the services. The rules say that an emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules 
say that urgently needed services are those needed because of an unforeseen illness or condition and it is not 
reasonable to get the services from the plan. Generally, these services are needed while the enrollee is outside 
of the service area. You can find this rule at 42 CFR Section 422.113. 
 
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 the Plan provided worldwide emergency coverage. You can get emergency care outside 
the United States. There is no worldwide coverage for care outside of the emergency room or emergency 
hospital admission. You can find this information on page 49 of the Plan's 2022 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 a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
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 the services of a Clinical Social Worker (CSW) may be covered when the provider is: 
 
-Legally authorized to practice clinical social work in the state where you provide services 
-Medicare doesnt statutorily preclude the services, and theyre reasonable and necessary 
-You provide services to diagnose and treat mental illnesses 
-Medicare doesnt pay CSWs under the CSW benefit category for CSW services to hospital inpatients 
-Medicare covers CSW services when furnished to hospital outpatients and pays for CSW services under the 
CSW benefit category when billed by the hospital under CSWs National Provider Identifier 
-Medicare doesnt pay under the CSW benefit category for CSW services furnished to patients under PHP by a 
hospital outpatient department or Community Mental Health Center 
-Medicare doesnt pay under the CSW benefit category for CSW services furnished to SNF inpatients and 
patients in Medicare-participating End-Stage Renal Disease facilities, if the services are required 
under the respective providers requirements for participation 
-Medicare may cover ancillary services that CSWs provide incident to the personal professional services of 
physicians, CPs, CNSs, NPs, PAs, or CNMs 
-Medicare doesnt cover services provided incident to your personal professional services 
 
You can find this information in the Medicare Learning Network Booklet: Medicare Mental Health. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say if one laboratory procedure evaluates multiple genes utilizing a next generation sequencing 
procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis current 
procedural terminology (CPT) code. If no CPT code accurately describes the procedure performed, the 
laboratory shall report CPT code 81479 (unlisted molecular pathology procedure) with one unit of service. The 
laboratory shall not report multiple individual CPT codes describing the component test results. If a single 
procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the 
procedure. You can find this rule in the Centers for Medicare and Medicaid Services, National Correct Coding 
Initiative Policy Manual Chapter X. 
 
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 if the same physician or other supplier entity does not furnish both the TC and PC of the 
diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the 
professional interpretation was furnished in a different payment locality from where the TC was furnished, the 
professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting 
physician. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual Chapter 13, Section 150 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 say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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 under certain circumstances, members may obtain services from out-of-network providers. 
You can find this information on page 57 of the Plan's 2021 Evidence of Coverage.