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 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 rate, facility or non-facility that a physician service is paid under the MPFS is determined by the Place of 
service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter 
with the physician, non-physician practitioner (NPP) or other supplier. In general, the POS code reflects the 
actual place where the beneficiary receives the face-to-face service and determines whether the facility or non-
facility payment rate is paid. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12 Section 20.4.2. 
 
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service 
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
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 fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, 
L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, 
L5858) is covered for beneficiaries whose functional level is 3 or above. You can find this rule in the Local 
Coverage Determination (LCD) for Lower Limb Prostheses (L33787). 
 
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. 
 
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 $390 copayment per day for days 1 to 5 for inpatient hospital care. You 
can find this information on pages 4-29 to 4-33 of the Plan's 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 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 $150 deductible which applies to certain items and services. The Plan deductible 
applies to the hospital care. You can find this information on page 2 of the Plan's 2022 Evidence of Coverage 
(EOC).  
 
The Plan contract also says that enrollees must pay a 4% coinsurance for inpatient hospital care, after the 
deductible is met. You can find this information on page 34 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 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 non-emergency ground transportation within our service area. Trips are limited to 75 miles, one-way, 
unless approved by the plan. Call at least 72 hours in advance to schedule routine trips, or anytime for urgent 
trips. Certain locations may be excluded. For more information about plan-approved locations, please call 
Member Services. You can find this information on page 109 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 state that a Group 3 power wheelchair with no power options is covered if: 
 
1. All of the coverage criteria for a power wheelchair are met; and 
2. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity; and 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation 
wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. 
The PT, OT, or practitioner may have no financial relationship with the supplier; and 
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional 
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection 
for the beneficiary. 
 
These rules are found in Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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 Signatera genetic testing services are only covered when coverage criteria under the policy 
have been met for (1) the diagnosis of disease progression, recurrence, or relapse for colon cancer and (2) 
monitoring of response to immune-checkpoint inhibitor therapy for any solid tumor. 
 
You can find this information in the Local Coverage Article (LCA): Billing and Coding: MolDX: Minimal 
Residual Disease Testing for Solid Tumor Cancers (A58454). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a manual wheelchair for use inside the home (K0005) is covered if: 
 Criteria A, B, C, D, and E are met; and 
 Criterion F or G is met. 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home.  
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker. 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
D. Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in 
MRADLs and the beneficiary will use it on a regular basis in the home. 
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities 
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function. 
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
You can find this rule in the Local Coverage Determination for Manual Wheelchair Bases, L33788. 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(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 that definitive drug testing is indicated when the results of the screen are presumptively positive; 
the results of the screen are negative, and this negative finding is inconsistent with the patient's medical history; 
and there is no presumptive test available, locally and/or commercially, as may be the case for certain synthetic 
or semi-synthetic opioids. You can find this rule in the Local Coverage Determination for Drug Testing 
L34645.  
 
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 diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary 
by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by 
another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of 
the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless 
there is no Part A coverage. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.3. 
 
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.
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 Facet Joint Interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet ALL the following criteria: 
-Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale. 
-Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated). 
-Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint 
synovial cyst). 
-There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
-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 (i.e., 
medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA ablations that are 
performed during the same day. You can find this rule in the Medicare Local Coverage Determination (LCD)- 
L35936, Facet Joint Interventions for Pain Management. 
 
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 clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
- Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance 
and a prosthesis does not enhance their quality of life or mobility. 
- Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at 
fixed cadence. Typical of the limited and unlimited household ambulator. 
- Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental 
barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
- Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community 
ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
- Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, 
exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active 
adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, 
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is 
covered for beneficiaries whose functional level is 3 or above. An axial rotation unit (L5982, L5984, L5985, 
L5986) is covered for beneficiaries whose functional level is 2 or above. You can find these rules in Local 
Coverage Determination (LCD) Lower Limb Prosthetics (L33787). 
 
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. 
 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 when services or supplies are rendered by a non-contracting, original Medicare, participating 
provider, there is no balance billing paid by either the Plan or the enrollee. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 4, Section 170.2. 
 
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 $185 copay per day for days 1-7 for inpatient hospital care. 
You can find this information on page 49 of the Plans 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 state that Spinal fusion should only be considered as a last step in the treatment of chronic back pain 
and is not indicated for most persons suffering from back pain. Lumbar spinal fusion surgery may be 
considered medically necessary and covered for the following indications:  
 
1. Lumbar spinal instability for any of the qualified indications when confirmed by appropriate diagnostic 
testing (e.g., radiographic imaging, biopsy, bone aspirate, bone scan and gallium scan): 
 
2. Spinal stenosis for a single level (for example, L4-L5) with associated spondylolisthesis (see classifications 
below in section 3) or other documented evidence of instability (for example, facet joint instability [iatrogenic] 
related to decompression), AND symptoms of spinal claudication and radicular pain. The pain must represent a 
significant functional impairment despite a history of 3 months of conservative therapy (non-surgical medical 
management) as clinically appropriate  
 
3. Spondylolisthesis manifested by back pain WITH OR WITHOUT spinal claudication, radicular pain, motor 
deficit when the criteria are met: 
     
4. Degenerative disc disease (DDD) in the absence of instability when all of the criteria have been met as 
clinically appropriate for the patients current episode of care 
 
5. Lumbar fusion following prior spinal surgery 
 
6. Treatment of pseudoarthrosis (i.e., nonunion of prior fusion) at the same level after 12 months from prior 
surgery and all of the qualifications are met (unless imaging demonstrates failed spinal instrumentation [for 
example, fractured rod or loosened screw 
 
You can find this information in the Local Coverage Determination (LCD) Lumbar Spinal Fusion for 
Instability and Degenerative Disc Conditions L33382. 
 
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.