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 adherence to therapy is defined as use of PAP =4 hours per night on 70% of nights during a 
consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as 
not reasonable and necessary. 
 
If the treating practitioner re-evaluation does not occur until after the 91st day but the evaluation demonstrates 
that the beneficiary is benefiting from PAP therapy as defined in criteria 1 and 2 above, continued coverage of 
the PAP device will commence with the date of that re-evaluation. 
 
Beneficiaries who fail the initial 12 week trial are eligible to re-qualify for a PAP device but must have both: 
 
    In-person clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond 
to PAP therapy; and, 
 
    Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-
night study 
 
You can find this information in the Local Coverage Determination (LCD) Positive Airway Pressure (PAP) 
Devices for the Treatment of Obstructive Sleep Apnea L33718. 
 
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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) 
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an 
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at 
the discretion of Medicare. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, National Coverage Determinations (NCD) Manual, Section 220.6.17. 
 
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 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 Flow cytometry is covered for the following indications: 
HIV Infection, Leukemia or Lymphoma, Organ Transplants, Carcinomas and Primary Immunodeficiencies. 
You can find the rules in the Local Coverage Determination (LCD) Flow Cytometry L35032, Local Coverage 
Article, Billing and Coding: Flow Cytometry A56676. 
 
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 vacuum erection devices (L7900) and related accessories (L7902) are statutorily non-
covered (see related Policy Article for additional details). 
 
You can find this information in the Local Coverage Determination (LCD) Vacuum Erection Devices (VED) 
L34824. 
 
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 under preventative services, Medicare Part B covers the basic lipid panel (total cholesterol, 
high density lipoprotein-cholesterol (HDL-C), triglycerides, and low density lipoprotein-cholesterol (LDL-C)) 
for cardiovascular (CV) disease screening, every 5 years when ordered by a doctor. 
 
NCD 190.23 covers lipid panel testing for symptomatic patients for evaluating atherosclerotic CV disease, to 
monitor the progress of patients on anti-lipid dietary management and pharmacologic therapy for various lipid 
disorders. Per NCD 190.23, Routine screening and prophylactic testing for lipid disorders are not covered by 
Medicare. While lipid screening may be medically appropriate, Medicare by statue does not pay for it. Lipid 
testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk 
factors such as family history, tobacco use, etc. 
 
This policy denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic 
(with signs and symptoms) patients with suspected or documented CV disease because panel testing is not 
specific to a given patients lipid abnormality or disease. The policy indicates the medical indication(s) based 
on published scientific articles and consensus guidelines for individual lipid biomarkers that may be covered to 
characterize a given lipid abnormality or disease, to determine a treatment plan or to assist with intensification 
of therapy. Each individual lipid biomarkers must be specifically ordered and the reason for the test order 
documented in the patients medical record. The policy denies coverage for all non-lipid biomarkers when used 
for CV risk assessment including but not limited to, biochemical, immunologic, and hematologic, and genetic 
biomarkers for CV risk assessment regardless of whether ordered in a panel or individually. You can find this 
information in Local Coverage Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment 
(L36362). 
 
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 certain services are packaged as part of the covered skilled nursing facility (SNF) stay.  The 
SNF is required to provide all necessary covered Part A services, uncluding services such as radiology 
mandated under consolidated billing. For example, if the patient goes to the hospital for a non-emergency x-
ray, the SNF will be responsible for the radiology charges.  You can find this rule at Centers for Medicare and 
Medicaid Services, Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 6, Section 
50.2.2. 
 
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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested items or services but is limited to 1 every 12 to 84 months. You can find this information on pages 67 
to 69 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 state that Medicare defines certain services as "inpatient-only", which means that the services are not 
appropriate to be furnished in an hospital outpatient department. There is no payment under the Outpatient 
Prospective Payment System for services that Medicare designates to be inpatient-only services. You can 
find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare 
Claims Processing Manual, Chapter 4, Section 180.7. 
 
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 generally, evaluation & management (E/M) services on the day before major surgery or on 
the day of surgery that result in the initial decision to perform surgery are not included in the global surgery 
payment for the major surgery. Therefore, these services may be billed and paid separately. The 57 modifier 
should be used in this instance. However, the 59 modifier should not be used with minor surgeries because the 
global period for minor surgeries does not include the day prior to the surgery. When the decision to perform 
the minor procedure is typically done immediately before the service, it is considered a routine pre-operative 
service and a visit or consultation is not billed in addition to the procedure. Medicare does not pay for an E/M 
service billed with 57 if it was provided on the day of, or the day before, a procedure with a 000- or 010-day 
global surgical period. You can find this rule at Centers for Medicare and Medicaid Services, MedLearn 
Matters Publication ICN 907166 entitled Global Surgery Booklet. 
 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules state that that starting April 4, 2022 and continues until the COVID-19 public health emergency 
(PHE) ends, people with Medicare Part B can get up to eight free over-the-counter tests for the month of April 
any time before April 30
th
 and can then get another set of eight free over-the-counter tests during each 
subsequent calendar month through the end of the COVID-19 PHE. You can find this information at: 
https://www.cms.gov/newsroom/fact-sheets/medicare-covers-over-counter-covid-19-tests. 
 
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. 
 
All Home Health Prospective Payment System (HH PPS) claims must be submitted with type of bill (TOB) 
0329. The HH PPS claim will include line-item detail describing all the services provided in the period of care. 
At a provider's option, any durable medical equipment, oxygen or prosthetics, and orthotics provided may also 
be billed on the HH PPS claim, and this equipment will be paid in addition to the period of care payment. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.10.4. 
 
The rules say that HHAs must submit HH PPS claims with the 4th digit of "9." These claims may be adjusted with 
code "7" or cancelled with code "8." A/B MACs (HHH) do not accept late charge bills, submitted with code "5," on 
HH PPS claims. To add services within the period of a paid HH claim, the HHA must submit an adjustment. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 10, Section 40.2. 
 
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. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. You can find this information 
on pages 4-72 to 4-93 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 does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 Plan contract provides supplemental (extra) coverage for a wellness allowance. This benefit includes 
reimbursement up to $150 per calendar year towards your cost for a membership in a qualified health club or 
fitness facility during the calendar year, covered instructional fitness classes, participation in wellness programs 
such as Matter of Balance, Chronic Disease self-management, diabetes workshop, Healthy Eating for 
Successful Living, Healthy IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise, Enhance 
Wellness, Fit For Your Life, AAA Senior Driving, memory fitness activities, acupuncture, and/or covered 
nutritional counseling sessions with a licensed nutritional counselor or registered dietician. You can find this 
information on pages 82-83 of the Plans 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 generally, evaluation & management (E/M) services on the day before major surgery or on 
the day of surgery that result in the initial decision to perform surgery are not included in the global surgery 
payment for the major surgery. Therefore, these services may be billed and paid separately. The 57 modifier 
should be used in this instance. However, the 57 modifier should not be used with minor surgeries because the 
global period for minor surgeries does not include the day prior to the surgery. When the decision to perform 
the minor procedure is typically done immediately before the service, it is considered a routine pre-operative 
service and a visit or consultation is not billed in addition to the procedure. Medicare does not pay for an E/M 
service billed with 57 if it was provided on the day of, or the day before, a procedure with a 000- or 010-day 
global surgical period. You can find this rule at Centers for Medicare and Medicaid Services, MedLearn 
Matters Publication ICN 907166 entitled Global Surgery Booklet. 
 
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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say claims must specify whether equipment is rented or purchased. For purchased equipment, the 
itemized bill or claim must also indicate whether equipment is new or used. If the provider or supplier fails to 
indicate on an assigned claim whether equipment was new or used, the contractor processing the claims 
assumes purchased equipment is used and process the claim accordingly, i.e., they pay on the basis of the used 
purchase fee. If an unassigned purchase claim does not specify whether the item was new or used, contractors 
develop the claim with the supplier. The following table indicates the HCPCS modifiers which are added to the 
equipment code to indicate its status: 
 
-BP: The beneficiary has been informed of the purchase and rental options and has elected to purchase the item  
-BR: The beneficiary has been informed of the purchase and rental options and has elected to rent the item  
-BU: The beneficiary has been informed of the purchase and rental options and after 30 days has not informed 
the supplier of his/her decision  
-KH: DMEPOS item, initial claim, purchase or first month rental  
-KI: DMEPOS item, second or third month rental  
-KJ: DMEPOS item, PEN pump or capped rental months four to fifteen  
-NR: New when rented (use the 'NR' modifier when an item that was new at the time of rental is subsequently 
purchased)  
-NU: New equipment  
-RR: Rental (use the 'RR' modifier when DME is to be rented)  
-UE: Used durable medical equipment 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual Chapter 20 130.9. 
 
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 page 3-4 of the Plan's 2023 
Evidence of Coverage.