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 payment for inpatient hospital services is made on the basis of a DRG (diagnosis related group).
Hospitals must provide proper information about the patient (i.e., age, sex, discharge status, principal and
secondary diagnoses, and procedures) in order for the correct DRG to be assigned. You can find this rule in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims
Processing Manual, Chapter 3, Section 20.2.1.

The rules say that the circumstances of inpatient admission always govern the selection of principal diagnosis.
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition
established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for
care." For reporting purposes, the definition for "other diagnoses" is interpreted as additional conditions that
affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures;
or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b
defines Other Diagnoses as "all conditions that coexist at the time of admission, that develop subsequently, or
that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which
have no bearing on the current hospital stay are to be excluded." You can find this information in the
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines
for Coding and Reporting, Sections II and III.

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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).

The rules say that as of January 1, 2013, for most evaluation and management (E&M) visit families, practitioners will select visit level based on the level of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner. For some types of visits (such as emergency department visits and critical care), in accordance with their CPT codes, practitioners do not have this choice and will use only MDM or only time to bill. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. You can find this rule in the Centers for Medicare & Medicaid Services (CMS), Internet Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.

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 64 in 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 state that Medicare covers application of skin substitutes to ulcers or wounds with failed response 
that are: 
 
- Partial or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone or 
sinus tracts, with a clean granular base; 
- Skin deficit at least 1.0 square centimeter (cm) in size; 
- Clean and free of necrotic debris or exudate; 
- Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by physical 
examination (Ankle-Brachial Index [ABI] of no less than 0.60) 
- For diabetic foot ulcers, the patients medical record reflects a diagnosis of Type 1 or Type 2 Diabetes and 
also reflects medical management for this condition. 
 
The rules say that simultaneous use of more than one product for the episode of wound is not covered. 
 
You can find this information in the Local Coverage Determination (LCD): Application of Bioengineered Skin 
Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041). 
 
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 Fixed Prosthodontics. The placement of a fixed prosthetic appliance will only be considered for
those exceptional cases where there is a documented physical or neurological disorder that would preclude
placement of a removable prosthesis. You can find this information on page 29 of the Plan's 2023 DentaQuest,
LLC Office Reference Manual.
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 custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive 
sleep apnea (OSA) is covered if criteria A - D are met. 
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-
related Policy Article for applicable diagnoses. 
B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3):  
1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or 
equal to 15 events per hour with a minimum of 30 events; or, 
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a 
minimum of 10 events and documentation of:  
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
b. Hypertension, ischemic heart disease, or history of stroke; or, 
3. If the AHI> 30 or the RDI> 30 and meets either of the following(a or b):  
a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
b. The treating practitioner determines that the use of a PAP device is contraindicated. 
C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who 
performed the clinical evaluation in criterion A.) 
D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. You can find this rule at Local Coverage Determination (LCD) L33611: Oral 
Appliances for Obstructive Sleep Apnea (eff. 8/8/21). 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 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, Section 3.3.2.1.

The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).

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 manual manipulation of the spine to correct subluxation. Subluxation is a partial dislocation
or misalignment of the vertebrae. As a medical diagnosis, specific medical requirements must be identified by
the provider. Prior authorization rules may apply. You pay nothing for each covered supplemental routine
chiropractic visit up to the plan maximum. You can see this on page 63 of the Plans 2023 Evidence of
Coverage.

The Plan contract says, in the Health and Wellbeing Benefit section, this benefit includes acupuncture,
naturopathy, routine chiropractic, massage therapy, and various CHPW recommended Wellbeing programs,
with up to a total of 25 services/programs combined per year. You can see this on page 71 of the Plans 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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 pages 38 and 39 
of the Plan's 2023 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 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 
intraoral complete series of radiographic images but is limited to 1 procedure code every 5 years. This benefit 
also includes the extractions but is limited to 2 procedure codes per calendar year. The the re-evaluation, the 
adjunctive pre-diagnostic test, the surgical stent, the extractions, the placement of intra-socket dressing, the 
medicaments, and the unspecified adjunctive procedure are not covered by the Plan's dental benefits. You can 
find this information on pages 57 to 58 and on pages 64 to 65 of the Plan's 2021 and 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 $375 copayment for outpatient surgery. You can find this information 
on page 71 of the Plan's 2023 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 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, Section 3.3.2.1.

The rules say that an L5859 (addition to lower extremity prosthesis, endoskeletal knee shin system 
power and programmable flexion/extension assist control) is only covered when the beneficiary meets 
all of the criteria below:
1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee
2. K3 functional level only
3. Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or 
quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled 
knee alone
4. Is able to make use of a product that requires daily charging
5. Is able to understand and respond to error alerts and alarms indicating problems with the 
function of the unit

If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and
necessary. You can find this in the Medicare Local Coverage Determination (LCD): Lower Limb Prostheses
(L33787).

The rules say for code L5859, the medical records should describe the nature and extent of the comorbidity of
the spine or the sound limb which is what is limiting this beneficiary to a household ambulator, and clearly
document how this feature will enable the beneficiary to function as a community ambulator. You can find this
in the Medicare Local Coverage Article (LCA) Lower Limb Prostheses - Policy Article (A52496).

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 provides up to $2,000 
for covered services each year. You can find this information on pages 75-78 of the Plan's 2023 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that code G0260 should be reported with an imaging code specific to the imaging modality 
employed. You can find this rule in the Local Coverage Determination, Billing and Coding Article: Sacroiliac 
Joint Injections and Procedures, A59233. 
 
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 one to two levels of facet joint injections, either unilateral or bilateral, are allowed per 
session per spine region. The need for a three or four-level procedure bilaterally may be considered under 
unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
You can find this information at Local Coverage Determination (LCD)-Facet Joint Interventions for Pain 
Management (L38803). 
 
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.