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 epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following requirements are met: 
- History, physical examination, and concordant radiological image-based diagnostic testing that supports 
one of the following: 
~ Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis 
~ Post-laminectomy syndrome, 
~ Acute herpes zoster associated pain. 
- Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality 
of life or function. An objective pain scale or functional assessment must be performed at baseline 
(prior to interventions). The same scale must be used at each follow-up for assessment of response. 
- Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute 
herpes zoster refractory to conservative management where a four (4) week wait is not required. 
 
Repeat ESI when the first injection directly and significantly provided improvement of the condition being 
treated may be considered medically reasonable and necessary when the medical record documents at least 
50% of sustained improvement in pain relief and/or improvement in function measured from baseline using 
same scale for at least three months. You can find these rules in Local Coverage Determination (LCD) Epidural 
Steroid Injections for Pain Management (L33906). 
 
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 effective for services performed on or after July 9, 2015, CMS has determined that the 
evidence is sufficient to add Human Papillomavirus (HPV) testing once every five years as an additional 
preventive service benefit under the Medicare program for asymptomatic beneficiaries aged 30 to 65 years in 
conjunction with the Pap smear test. CMS will cover screening for cervical cancer with the appropriate U.S. 
Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA approved 
labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, 
National Coverage Determinations (NCD) Manual: Screening for Cervical Cancer with Human Papillomavirus 
(HPV) (NCD 210.2.1. 
 
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 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 state that the Pigmented Lesion Assay (PLA) is indicated only for use on pigmented skin lesions, for 
which a diagnosis of melanoma is being considered. The test may only be ordered by clinicians who evaluate 
pigmented skin lesions and perform biopsies. The test is covered for use as a source of information on whether 
or not to perform a biopsy. You can find this information in Local Coverage Determination (LCD): MolDX: 
Pigmented Lesion Assay (L38151). 
 
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 36 one-way trips per year. Each one-way trip must not exceed 50 miles of driving distance. You 
can find this information in Chapter 4 on pages 4-76 to 4-77 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. 
 
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 a patient lift is covered if transfer between bed and a chair, wheelchair, or commode is 
required and, without the use of a lift, the beneficiary would be bed confined. 
 
A patient lift described by codes E0630, E0635, E0639, or E0640 is covered if the basic coverage criteria are 
met. If the coverage criteria are not met, the lift will be denied as not reasonable and necessary. 
 
A multi-positional patient transfer system (E0636, E1035, E1036) is covered if both of the following criteria 1 
and 2 are met: 
 
The basic coverage criteria for a lift are met; and 
The beneficiary requires supine positioning for transfers 
If either criterion 1 or 2 is not met, codes E0636, E1035, and E1036 will be denied as not reasonable and 
necessary. 
 
If coverage is provided for code E1035 or E1036, payment will be discontinued for any other mobility assistive 
equipment, including but not limited to: canes, crutches, walkers, rollabout chairs, transfer chairs, manual 
wheelchairs, power-operated vehicles, or power wheelchairs. 
 
Code E0621 is covered as an accessory when ordered as a replacement for a covered patient lift. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Patient Lifts (L33799). 
 
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 for each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. You can find this rule at Local Coverage Determination (LCD) L33930: 
Facet Joint Interventions for Pain Management (eff. 4/25/21). 
 
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. 
 
The rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a three or four-level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. A session is a time period, which includes all 
procedures that are performed during the same day. You can find this rule in the Local Coverage Determination 
(LCD) - Facet Joint Interventions for Pain Management (L33930) - Effective April 25, 2021. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a group 2 or 3 power wheelchair with multiple power options will be covered if the 
beneficiary either uses a ventilator which is mounted on the wheelchair or meets coverage criteria for a power 
tilt and recline seating system and the system is being used on the wheelchair. You can find these rules in Local 
Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
A power seating system  tilt only, recline only, or combination tilt and recline  with or without power 
elevating legrests will be covered if the beneficiary is at high risk for development of a pressure ulcer and is 
unable to perform a functional weight shift; or the beneficiary utilizes intermittent catheterization for bladder 
management and is unable to independently transfer from the wheelchair to bed; or the power seating system is 
needed to manage increased tone or spasticity. You can find these rules in Local Coverage Determination 
(LCD): Wheelchair Options/Accessories (L33792). 
 
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 - Submission of the Notice of Admission (NOA) 
(Rev. 11447, Issued: 06-06-22, Effective: 01-01-22, Implementation: 05-26-22). 
 
The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 1, Section 80.3.1. 
 
The rules say that home health agencies (HHAs) must send the notice of admission (NOA) to the A/B MAC by 
mail, electronic data interchange (EDI), or direct data entry (DDE). EDI submissions require additional data 
not required by the NOA itself, to satisfy transaction standards. This data is described in a companion guide 
available on the Centers for Medicare and Medicaid Services website. HHAs may voluntarily agree to adopt 
the companion guide and use it to submit EDI NOAs at any time. The rules say that the admission date on the NOA must always match the From date. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 10, Section 40.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height 
adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. 
You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds And 
Accessories (L33820). 
 
The rules say a patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required 
and, without the use of a lift, the beneficiary would be bed confined. 
 
A patient lift described by codes E0630, E0635, E0639, or E0640 is covered if the basic coverage criteria are 
met. If the coverage criteria are not met, the lift will be denied as not reasonable and necessary. 
 
A multi-positional patient transfer system (E0636, E1035, E1036) is covered if both of the following criteria 1 
and 2 are met: 
 
    The basic coverage criteria for a lift are met; and 
    The beneficiary requires supine positioning for transfers 
 
If either criterion 1 or 2 is not met, codes E0636, E1035, and E1036 will be denied as not reasonable and 
necessary. 
 
If coverage is provided for code E1035 or E1036, payment will be discontinued for any other mobility assistive 
equipment, including but not limited to: canes, crutches, walkers, rollabout chairs, transfer chairs, manual 
wheelchairs, power-operated vehicles, or power wheelchairs. Code E0621 is covered as an accessory when 
ordered as a replacement for a covered patient lift. You can find this information in Medicare's Local Coverage 
Determination (LCD): Patient Lifts (L33799). 
 
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 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. 
 
The rules say that AlloSure Heart is covered when used in conjunction with AlloMap
 
to assess the 
probability of allograft rejection in heart transplant recipients with clinical suspicion of rejection and to inform 
clinical decision-making about the necessity of a heart biopsy in such patients at least 55 days post-transplant in 
conjunction with standard clinical assessment. To report a service, select CPT code 81479. You can find this 
rule in the Local Coverage Determination and Article for Molecular Diagnostics (MolDX): AlloSure or 
Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts, L38355 and A57380.  
 
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 47 of the Plan's 2021 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules state that payment may be made for a one-time ultrasound screening for AAA for beneficiaries who 
meet the following criteria: 
(i) receives a referral for such an ultrasound screening from the beneficiarys attending physician, 
physician assistant, nurse practitioner or clinical nurse specialist; 
(ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered 
ultrasound diagnostic services; 
(iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and 
(vi) is included in at least one of the following risk categories-- 
      (I) has a family history of abdominal aortic aneurysm; 
      (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or 
      (III) is a beneficiary who manifests other risk factors in a beneficiary category recommended for 
screening by the United States Preventive Services Task Force regarding AAA, as specified by the 
Secretary of Health and Human Services, through the national coverage determination process. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 110.2. 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.