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 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 health 
plan contract says up to twenty-four (24) one-way trips are covered each year (limited to ground transportation 
only). You can find this information in Chapter 4 on page 4-53 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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules state that a physician order or clear intent to order specific lab services in the medical record, is 
required for Medicare-covered laboratory services. You can find this information in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 
15, 80.6. 
 
The rules state that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. You can find this information in the 42 CFR  410.32.  
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 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 at Local Coverage Determination (LCD) L36920: Epidural Steroid Injections for Pain Management 
(eff. 12/11/21). 
 
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 MA plans may choose to offer some benefits to enrollees in addition to the covered 
Medicare Part A and Part B (and Part D, as applicable) benefits they are required to offer if the item or service 
also meets the criteria described in sections 30 and 40 of this chapter. You can find this information in 
Medicare Managed Care Manual Chapter 4, Section 30.1. 
 
Medicare does not reimburse separately for sales tax. You can find this the Centers for Medicare and Medicaid 
Services, Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 
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. The Plan 
contract says that the Plan covers items and services in accordance with Medicare rules. This plan covers 
certain approved, non-prescriptions, over-the-counter (OTC) drugs and health related items, up to $107 every 
quarter.You can find this information on pages 83 to 85 of the Plans 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 state that  intra-operative testing may be considered reasonable and necessary for the following: 
 
    Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is 
risk of cerebral or spinal cord ischemia 
    Resection of epileptogenic brain tissue or tumor 
    Resection of brain tissue close to the primary motor cortex and requiring brain mapping 
    Protection of cranial nerves: 
        Resection of tumors involving the cranial nerves 
        Cavernous sinus tumors 
        Microvascular decompression of cranial nerves 
        Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum 
        Oval or round window graft 
    Endolymphatic shunt for Meniere's disease 
    Vestibular section for vertigo 
    Correction of scoliosis or deformity of spinal cord involving traction of the cord 
    Protection of spinal cord where work is performed in close proximity to cord as in the placement or removal 
of old hardware or where there have been numerous interventions 
    Spinal instrumentation requiring pedicle screws or distraction 
    Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication 
where function of spinal cord or spinal nerves is at risk 
    Spinal cord tumors and spinal fractures (with the risk of cord compression) 
    Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves 
    Surgery or embolization for intracranial AV malformations 
    Surgery for arteriovenous malformation of spinal cord 
    Embolization of bronchial artery AVMs or tumors 
    Cerebral vascular aneurysms 
    Surgery for intractable movement disorders     Arteriography, during which there is a test occlusion of the carotid artery 
    Circulatory arrest with hypothermia (does not include surgeries performed under circulatory bypass [e.g., 
CABG, ventricular aneurysms]) 
    Distal aortic procedures, where there is risk of ischemia to spinal cord 
    Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks 
    Basal ganglia movement disorders 
    Surgery as a result of traumatic injury to spinal cord/brain 
    Deep brain stimulation, and 
    Certain thyroid surgeries (see below for additional guidance) 
 
You can find this information in the Local Coverage Determination (LCD) Intraoperative Neurophysiological 
Testing L35003. 
 
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 in Chapter 3 on page 40 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 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) and Medicare Local Coverage 
Determination (LCD): Power Mobility Devices (L33789). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 beginning in July 2015, claims for compounded drugs shall be submitted using a 
compounded drug, not otherwise classified (NOC) code. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 17, Section 20.1.2. 
 
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 a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height 
adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) Hospital Beds And Accessories 
L33820. 
 
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 contractors must edit institutional claims to ensure the following: 
- that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X. 
- that no more than one GN, GO or GP modifier is reported on the same service line. 
- that revenue codes and modifiers are reported only in the following combinations: 
~ Revenue code 42x (physical therapy) lines may only contain modifier GP 
~ Revenue code 43x (occupational therapy) lines may only contain modifier GO 
~ Revenue code 44x (speech-language pathology) lines may only contain modifier GN. 
~ that discipline-specific evaluation and re-evaluation Healthcare Common Procedure Coding 
System (HCPCS) codes are always reported with the modifier for the associated discipline (e.g. 
modifier GP with a HCPCS code for a physical therapy evaluation). 
 
Contractors return to the provider institutional claims that do not meet one or more of these conditions. You 
can find these rules Medicare Claims Processing Manual Chapter 5, Section 20.1. 
 
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 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 $50 copayment for Medicare-covered vision services received from an 
in-network specialist or 50% coinsurance for Medicare-covered vision services received from an out-of-
network specialist. You can find this information on pages 75-76 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 screening colonoscopies (HCPCS G0105) may be paid when performed by a doctor of 
medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing 
colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered HCPCS 
G0105 screening colonoscopy was performed). (See CMS Publication 100-04, Medicare Claims Processing 
Manual, Chapter 18, Section 60.2) 
 
Characteristics of the High Risk Individual: 
 
An individual at high risk for developing colorectal cancer has one or more of the following: 
 
    A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp; 
 
    A family history of familial adenomatous polyposis; 
 
    A family history of hereditary nonpolyposis colorectal cancer; 
 
    A personal history of adenomatous polyps; 
 
    A personal history of colorectal cancer; or 
 
    Inflammatory bowel disease, including Crohns Disease, and ulcerative colitis. 
 
(See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 60.3) 
 
You can find this information in the Local Coverage Article (LCA) Billing and Coding: Colorectal Cancer 
Screening  Medical Policy Article (A52378). 
 
 
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 molecular diagnostic tests used to assist in risk stratification of melanoma patients are 
covered when: 
The patient has a personal history of melanoma AND: 
        Either: 
            Has Stage T1b and above OR 
            Has T1a with documented concern about adequacy of microstaging 
Is undergoing workup or being evaluated for treatment, AND         
Does not have metastatic disease AND         
Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other 
information is >5% AND        
Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended use of 
the test 
 
You can find this information in the Local Coverage Determination (LCD): MolDX: Melanoma Risk 
Stratification Molecular Testing (L37725). 
 
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 if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
service. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
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). 
 
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 does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
 
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
 
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
You can find this rule at 42 CFR Section 411.15(b). 
  
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
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 
offers a supplemental (extra) benefit to cover routine vision services which are not covered by Original 
Medicare. This benefit includes one routine eye exam with refraction and dilation every year and up to $300 
toward the purchase and fitting of eyeglasses or contact lenses at a network optical provider (1 per calendar 
year). This benefit is provided only through the specified vision vendor network. You can find this information 
on pages 87-88 of the Plan's 2021 Evidence of Coverage.