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. 
 
he 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 say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic 
preparations will be considered medically reasonable and necessary when ALL of the following conditions are 
met: 
 
    1. The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily 
    living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 
    2. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space 
    narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
    3. If appropriate, other diagnoses have been excluded by appropriate evaluation and management services,  
    laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a  
    diagnosis other than osteoarthritis of the knee). 
    4. The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
        - Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss,  
         physical therapy if indicated); and 
        - If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product 
         prescribing information. 
    5. The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular  
   corticosteroid injection therapy when inflammation is a significant component of the patients symptoms and  
   intra-articular corticosteroids are not contraindicated. 
 
You can find this information in the Local Coverage Determination (LCD): Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427). 
 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 4 of the 2023 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 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. You can find this rule in the Local Coverage Determination 
(LCD) - MolDX: AlloSure or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts (L38355) - 
Effective December 6, 2020. 
 
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 state that all services billed by the SNF (including those furnished under arrangements with an 
outside supplier) for a resident of a SNF in a covered Part A stay are included in the SNF's Part A bill. If a 
resident is not in a covered Part A stay (Part A benefits exhausted, posthospital or level of care requirements 
not met), the SNF is required to bill for all physical therapy, occupational therapy, and/or speech-language 
pathology services provided to a SNF resident under Part B. The consolidated billing provision requires that 
effective for services and items furnished on or after July 1, 1998, payment is made directly to the SNF. 
 
Thus, SNFs are no longer able to "unbundle" services to an outside supplier that can then submit a separate bill 
directly to an A/B MAC (B) or DME MAC for residents in a Part A stay, or for SNF residents receiving 
physical therapy, occupational therapy, and/or speech-language pathology services paid under Part B. Instead, 
the SNF must furnish the services either directly or under an arrangement with an outside supplier or provider 
of services in which the SNF (rather than the supplier or provider of services) bills Medicare. Medicare does 
not pay amounts that are due a provider to any other person under assignment, or power of attorney, or any 
other direct payment arrangement. As a result, the outside supplier must look to the SNF (rather than the A/B 
MAC (A), or (B), or DME MAC or the beneficiary) for payment. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 6, Section 10.1. 
 
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 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 50 of the Plan's 2023 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 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 physician shall not unbundle services that are integral to a more comprehensive procedure. 
A physician shall not report multiple Healthcare Common Procedure Coding System (HCPCS)/Current 
Procedural Terminology (CPT) codes when a single comprehensive HCPCS/CPT code describes these 
services. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I. 
 
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 percutaneous transluminal angioplasty (PTA) is covered when used under the following 
conditions: 
1. Treatment of Atherosclerotic Obstructive Lesions 
- In the lower extremities, i.e., the iliac, femoral, and popliteal arteries, or in the upper extremities, 
i.e., the innominate, subclavian, axillary, and brachial arteries. The upper extremities do not 
include head or neck vessels. 
- Of a single coronary artery for patients for whom the likely alternative treatment is coronary 
bypass surgery and who exhibit the following characteristics: 
~ Angina refractory to optimal medical management; 
~ Objective evidence of myocardial ischemia; and 
~ Lesions amenable to angioplasty. 
- Of the renal arteries for patients in whom there is an inadequate response to a thorough medical 
management of symptoms and for whom surgery is the likely alternative. PTA for this group of 
patients is an alternative to surgery, not simply an addition to medical management. 
- Of arteriovenous dialysis fistulas and grafts when performed through either a venous or arterial 
approach. 
2. Concurrent with carotid stent placement in Food & Drug Administration (FDA) approved category B 
investigational device exemptions (IDE) clinical trials 
3. Concurrent with carotid stent placement in FDA-approved post approval studies 
4. Concurrent with carotid stent placement in patients at high risk for carotid endarterectomy 
 
You can find these rules in National Coverage Determination (NCD) Percutaneous Transluminal Angioplasty 
(PTA) (20.7). 
 
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 say beginning January 1, 2021, home health agencies (HHAs) will need to submit Requests for 
Anticipated Payment (RAPs) for each admission to home health.  
 
The rules say starting in calendar year 2021, a payment reduction will apply when the HHA does not submit 
the RAP within 5 calendar days from the start of care date ("admission date" and "from date" on the claim will 
match the start of care date) for the first 30-day period of care in a 60-day certification period, and within 5 
calendar days of the "from date" for the second 30-day period of care in the 60-day certification period. The 
payment reduction will be equal to a 1/30th reduction to the 30-day period payment amount for each day from 
the home health start of care date/admission date, or "from date" for subsequent 30-day periods, until the date 
the HHA submits the RAP. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Transmittal 10403, Change 
Request 11855. 
 
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 a status indicator of T represents a code that is only paid if there are no other services 
payable under the physician fee schedule billed on the same date by the same provider. If any other services 
payable under the physician fee schedule are billed on the same date by the same provider, these services are 
bundled into the physician services for which payment is made. You can find this rule in Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
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 
coverage for the requested items or services, but only when they are received from an in-network provider. If 
your plan does not have a Point of Service option, dental services will not be covered for out-of-network 
providers. You can find this information in Chapter 4 on page 74 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 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 $200 copayment for outpatient hospital surgery services. You can find 
this information on page 91 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). 
 
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 20% coinsurance for in-network Part B drugs that are administered by a 
provider. You can find this information on page 93 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 that erythropoietin stimulating agent (ESAs) are covered for the following indications: 
  Treatment of significant anemia in patients with non-myeloid malignancies where anemia is specifically due 
to concomitantly administered chemotherapy;  
  Treatment of symptomatic anemia related to end-stage renal disease (ESRD) and Stages IIIb, IV and V 
chronic kidney disease (CKD);  
  Treatment of anemia induced by AZT (Zidovudine) used in HIV/AIDS therapy  
  Treatment of selected patients with anemia related to low prognostic risk myelodysplastic syndrome and 
some myeloproliferative neoplasms;  
  Peri-surgical adjuvant therapy for purposes of allogenic RBC transfusion reduction 
 
You can find this rule at Local Coverage Determination (LCD) L39237: Erythropoiesis Stimulating Agents 
(eff. 7/24/22). 
 
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 81 of the 2023 Evidence of Coverage (EOC).