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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 services in the global surgical package include follow-up visits during the postoperative 
period of the surgery that are related to the recovery from the surgery. 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 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 stress testing with cardiac imaging will be considered medically reasonable and necessary for 
patient experiencing new, recurrent, or worsening cardiac symptoms, including otherwise angina equivalent 
symptoms, along with a new or previously unrecognized uninterpretable electrocardiogram (ECG) or 
evaluation of chest pain syndrome after revascularization or in patients with intermediate to high pre-test 
probability for coronary artery disease, regardless of ECG interpretability or ability to exercise. You can find 
this rule in the Local Coverage Determination (LCD)  Cardiology Non-emergent Outpatient Stress Testing 
(L35083). 
 
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 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 $285 copayment per day, for days 1-7 for inpatient hospital care. For 
each Medicare-covered hospital stay, you are required to pay the applicable cost sharing, starting with day 1 
each time you are admitted. Cost sharing does not apply on the day of discharge. You can find this information  
on page 50 of the Plan's 2021 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 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 also say that payment may be made under the physician fee schedule for the professional component 
of physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by 
hospital physicians. You can find this in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-04, Chapter 12, Section 60. 
 
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. 
Medicare rules say that a biomarker test, such as the ExoDx Prostate IntelliScore (ESI), is covered once in men 
 45 years old ( 50 years old for EPI) prior to initial biopsy, with confirmed* moderately elevated PSA (>3 
and <10 ng/mL; 4 and <10 ng/mL in men >75 years old) with both the following:   
1. No other relative indication for prostate biopsy including any of the following: 
a. Digital rectal examination suspicious for cancer 
b. Positive multiparametric magnetic resonance imaging (MRI) (if done) 
c. Other major risk factor for prostate cancer including:  
i. Ethnicity at higher risk for prostate cancer 
ii. First-degree relative with prostate cancer 
iii. High-penetrance prostate cancer risk gene(s) per National Comprehensive Cancer 
Network (if known) 
2. No other relative contraindication for prostate biopsy including ANY of the following: 
a. <10 year life expectancy 
b. Invasive treatment for benign prostatic disease or taking medications that influence serum PSA 
levels within 6 mo. 
c. Active prostatitis on antibiotics 
You can find this rule in Local Coverage Determination (LCD): Biomarker Testing (Prior to Initial Biopsy) for 
Prostate Cancer Diagnosis (L37733). 
 
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 on page 98 of the Plan's 2022 
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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
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 state that left prefrontal repetitive transcranial magnetic stimulation (rTMS) of the brain is considered 
medically necessary for use in an adult who meets all four of the following criteria: 
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) single or recurrent episode; and 
2. One or more of the following: 
- Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically 
significant response to a single trial of psychopharmacologic agents in the current depressive 
episode; or 
- Inability to tolerate psychopharmacologic agents as evidenced by two trials of 
psychopharmacologic agents from two different agent classes; or 
- History of response to rTMS in a previous depressive episode; or 
- A history of response to electroconvulsive treatment (ECT) in a previous or current episode or 
an inability to tolerate ECT, or is a candidate for, but has declined ECT and rTMS is considered 
a less invasive treatment option. 
3. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an 
adequate frequency and duration without significant improvement in depressive symptoms as 
documented by standardized rating scales that reliably measure depressive symptoms. 
4. The order for treatment (or retreatment) is written by a psychiatrist (MD or DO) who has examined the 
patient and reviewed the record. The psychiatrist will have experience in administering TMS therapy. 
The treatment shall be given under direct supervision of a qualified physician (physician present in the 
area and immediately available but does not necessarily personally provide the treatment). 
 
You can find these rules in Local Coverage Determination (LCD) Repetitive Transcranial Magnetic 
Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L37088). 
 
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 providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-T9, 
E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate. Many 
MUEs are based on the assumption that correct modifiers are used. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 20.9.3.2 
 
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 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). 
 
A bacterial urine culture is a laboratory procedure performed on a urine specimen to establish the probable 
etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a urine culture. 
A urine culture may also be used as part of the evaluation and management of another related condition. The 
procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms present, and 
quantification of types present based on morphologic criteria. Isolates deemed significant may be subjected to 
additional identification and susceptibility procedures as requested by the ordering physician. The physician's 
request may be through clearly documented and communicated laboratory protocols. 
 
You can find this rule at National Coverage Determination (NCD) for Urine Culture, Bacterial (190.12). 
 
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 the codes describing bundled payments made to OTPs are HCPCS codes G2067-G2075. 
There are add-on codes described by HCPCS codes G2076-G2080, HCPCS codes G2215, G2216, and G1028. 
Only an entity enrolled with Medicare as an OTP can bill these codes. Additionally, OTPs are limited to billing 
only these codes describing bundled payments, and may not bill for other codes, such as those paid under the 
PFS. Section 1833 (s)(2)(HH)(jjj))) of the Act recognizes Free-Standing Opioid Treatment Program Facilities 
as "providers of services" but only for furnishing Opioid Treatment Program services. Applicable provider 
ranges are xx9900-xx9999 billed on a claim with a type of bill 087x. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 39, Sections 30.6 and 50.1(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 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. 
 
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. 
 
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 $50 copayment physician/practitioner services, a $45 copayment for 
outpatient diagnostic tests, and a 20% coinsurance for Medicare Part B prescription drugs. You can find this 
information in Chapter 4 on page 90 for Part B drugs, x-ray on page 92, and specialist visits on page 106 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. 
 
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 supplemental (extra) benefits. This benefit includes a Wellness Allowance for 
up to $150 per calendar year towards your cost for 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 79 to 80 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 $45 copayment for each specialist visit. You can find this information 
on page 96 of the Plan's 2022 Evidence of Coverage (EOC).  
 
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 $440 copayment per visit for outpatient procedures at a non-preferred 
facility. You can find this information on page 94 of the Plan's 2022 EOC.  
 
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 $90 copayment for vascular studies. You can find this information on 
page 88 of the Plan's 2022 EOC.