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 a physician who is writing prescriptions for medications to treat chronic pain can manage a 
patient better if the physician knows whether the patient is consuming another medication or substance, which 
could suggest the possibility of substance use disorder or lead to drug-drug interactions. Additionally, drug 
testing may help the physician monitor for medication adherence, efficacy, side effects, and patient safety in 
general. 
 
Ongoing testing may be medically reasonable and necessary based on the patient history, clinical assessment, 
including medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, 
indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect 
or behavioral pattern. The frequency of testing must be based on a complete clinical assessment of the 
individuals risk potential for abuse and diversion using a validated risk assessment interview or questionnaire 
and should include the patients response to prescribed medications and the side effects of medications.  
 
You can find this information in the Local Coverage Determination (LCD): Controlled Substance Monitoring 
and Drugs of Abuse Testing (L35006). 
 
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 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.7,8 If a patient fails to respond well to the initial ESI, a 
repeat ESI after 14 days can be performed using a different approach, level and/or medication, if appropriate, 
with the rationale and medical necessity for the second ESI documented in the medical record. You can find 
this rule in Local Coverage Determination (LCD) Epidural Steroid Injections for Pain Management L36920. 
 
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 therapeutic embolization is covered when done for hemorrhage, and for other conditions 
amenable to treatment by the procedure, when reasonable and necessary for the individual patient. You can 
find this rule at Centers for Medicare and Medicaid Services, Internet-Only Manual 100-03, Medicare National 
Coverage Determinations Manual 20.28 
 
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 Section 1833(e) of the Social Security Act precludes payment to any provider of services 
unless "there has been furnished such information as may be necessary in order to determine the amounts due 
such provider". It is expected that the beneficiary's medical records will reflect the need for the care provided. 
The beneficiary's medical records include the treating practitioners office records, hospital records, nursing 
home records, home health agency records, records from other healthcare professionals and test reports. This 
documentation must be available upon request. In order to justify payment for Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS) items, suppliers must meet the following requirements: 
 
1. Standard written order (SWO) 
2. Medical record information (including continued need/use if applicable) 
3. Correct coding 
4. Proof of delivery 
 
You can find this rule in the Local Coverage Determination (LCD) - Transcutaneous Electrical Nerve 
Stimulators (L33802) - Effective November 20, 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 say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 122 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. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The National Coverage Determinations (NCD) states that "cochlear implantation may be covered for treatment 
of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss. You can find this rule in 
National Coverage Determination (NCD): Cochlear Implantation (50.3). 
 
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 for all beneficiaries receiving home health services in 2021 whose services will continue in 
2022, the Home Health Agency (HHA) shall submit a Notice of Admission (NOA) with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. For example, if 
a period of care begins in 2021 and ends on January 10, 2022, the HHA submits an NOA with an admission 
date of January 11, 2022, and then submits a claim when the 30-day period of care is over. The HHA should 
submit the January 11, 2022, admission date on all subsequent claims until the beneficiary is discharged and 
another NOA is required. This is to ensure the claim is matched to the correct NOA and the correct receipt date 
is used for payment. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10. 
 
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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules state that equipment which the enrollee owns or is a capped rental item may be replaced in cases of 
loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, 
flood). A physicians order and/or new Certificate of Medical Necessity (CMN), when required, is needed to 
reaffirm the medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day 
usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear 
takes into consideration the reasonable useful lifetime of the equipment. If the item of equipment has been in 
continuous use by the enrollee on either a rental or purchase basis for the equipments useful lifetime, the 
enrollee may elect to obtain a new piece of equipment. Replacement may be reimbursed when a new physician 
order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. The reasonable 
useful lifetime of durable medical equipment is determined through program instructions. In the absence of 
program instructions, A/B MACS (B) may determine the reasonable useful lifetime (RUL) of equipment, but in 
no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment is 
delivered to the enrollee, not the age of the equipment. Replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair 
up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the 
enrollee. These rules can be found in the Medicare Benefit Policy Manual Chapter 15, Section 110.2 for 
Repairs, Maintenance, Replacement, and Delivery. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Effective for dates of service on or after October 9, 2014, The CologuardTM test is covered 
once every three years for Medicare beneficiaries that meet all of the following criteria: 
1. Age 50 to 85 years, and, 
2. Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower 
gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal 
immunochemical test (iFOBT)), and, 
3. At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal 
cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history 
of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis 
colorectal cancer). 
 
You can find this rule in the Medicare National Coverage Determination (NCD) for Colorectal Cancer 
Screening Tests, 210.3 
 
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 say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 25 to 26 of the cost-sharing rider to 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 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 a national definition of a global surgical package has been established to ensure that payment 
is made consistently for the same services across all A/B MAC (B) jurisdictions, thus preventing Medicare 
payments for services that are more or less comprehensive than intended. The national global surgery policy 
became effective for surgeries performed on and after January 1, 1992. 
 
The Medicare approved amount for these procedures which have the appropriate entry in field 16 of the 
Medicare Physicians Fee Schedule (MFSDB) includes payment for preoperative visits, intra-operative 
services, complications following surgery, postoperative visits, postsurgical pain management, supplies and 
miscellaneous services furnished in any setting and related to the surgery when furnished by the physician who 
performs the surgery.  
 
The rules also say that modifiers were established to simplify billing for visits and other procedures which are 
furnished during the postoperative period of a surgical procedure, but which are not included in the payment 
for the surgical procedure.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40. 
 
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 allows payment for one annual wellness visit (AWV) for enrollees who have not 
had an AWV within the past 12 months. 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 140. 
 
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 covers annual wellness visit. This is covered once every 12 months. You can 
find this information on page 57 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 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 one-way trips to plan-approved locations every year. You can find this information on page 63 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 CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(A). 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 pages 23 to 30 of the Plan's 
2022 Evidence of Coverage (EOC).