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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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(s) 31 to 40 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 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 state that when services are furnished by a mobile unit, they are often provided to serve an entity for 
which another Place of service (POS) code exists. For example, a mobile unit may be sent to a physician's 
office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already 
exists, providers should use the POS code for that entity. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
26, Section 10.5. 
 
The rules say that procedures involving the use of contrast media and procedures involving fluoroscopy are not 
covered under the portable x-ray provision. 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 
80.4.4. 
 
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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
Licensed Professional Counselors frequently attempt to enroll in Medicare but are not eligible to do so; no 
statute permits them to bill Medicare. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 
10.2.8  
 
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 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. Diagnosis codes not listed do not support medical necessity. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determination (NCD) for Bacterial Urine Culture, 190.12, and the NCD Coding Policy Manual and Change 
Report. 
 
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 one iStent, iStent inject, or Hydrus device per eye will be considered medically reasonable 
and necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the 
individual is currently being treated with an ocular hypotensive medication and the procedure is being 
performed in conjunction with cataract surgery. You can find this information in the Local Coverage 
Determination (LCD): Micro-Invasive Glaucoma Surgery (MIGS) (L37244). 
 
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 effective January 1, 2017, ESRD facilities, both hospital based and freestanding are able 
to furnish dialysis to AKI patients and receive payment under the ESRD PPS. Medicare will pay ESRD 
facilities for the dialysis treatment using the ESRD PPS base rate adjusted by the applicable ESRD PPS wage 
index. In addition to the dialysis treatment, the ESRD PPS base rate pays ESRD facilities for other items and 
services considered to be renal dialysis services as defined in 42 CFR 413.171. No separate payment is made 
for those services considered to be renal dialysis services as payment is included in the ESRD PPS base rate. 
 
Other items and services that are furnished to beneficiaries with AKI that are not considered to be renal dialysis 
services but are related to their dialysis as a result of their AKI, would be separately payable, this includes 
drugs, biologicals, laboratory services, and supplies that ESRD facilities are certified to furnish and that would 
otherwise be furnished to a beneficiary with AKI in a hospital outpatient setting. AKI claims are billed on the 
072X type of bill with condition code 84. ESRD facilities are required to include revenue code 082X, 083x, or 
088x for the modality of dialysis furnished with the Current Procedural Terminology (CPT) code G0491 
(Dialysis procedure at a Medicare certified ESRD facility for Acute Kidney Injury without ESRD). 
 
AKI claims do not receive payment adjustments for comorbidities, TDAPA, TPNIES or outlier. The ESRD 
network reduction is not applicable to AKI claims. 
 
You can find these rules in the Centers for Medicare & Medicaid Services, Medicare Claims Processing 
Manual Chapter 8, 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 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 33 to 34 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 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 in order to have a service covered as incident-to the services of a physician, it must be 
performed under the direct supervision of the physician as an integral part of the physicians personal in-office 
service. In addition, the physician must be physically present in the same office suite and be immediately 
available to render assistance if that becomes necessary. 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, 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. 
 
The rules state that a group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to 
improve over the past month, during which time the beneficiary has been on a comprehensive ulcer 
treatment program including each of the following: 
a. Use of an appropriate group 1 support surface, and 
b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
c. Appropriate turning and positioning, and 
d. Appropriate wound care, and 
e. Appropriate management of moisture/incontinence, and 
f. Nutritional assessment and intervention consistent with the overall plan of care 
2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis, 
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days, and has been on a group 2 or 3 support surface immediately prior to discharge from a 
hospital or nursing facility within the past 30 days 
 
You can find this information in the Local Coverage Determination (LCD): Pressure Reducing Support 
Surfaces- Group 2 (L33642). 
 
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 when a comparative imaging study is performed to assess potential complications or 
completeness of a procedure (e.g., post-reduction, post-intubation, post-catheter placement, etc.), the 
professional component of the CPT code for the post-procedure imaging study is not separately payable and 
shall not be reported. You can find this rule in the Centers for Medicare and Medicaid Services, National 
Correct Coding Initiative Policy Manual for Medicare Services, Chapter 9. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that transcutaneous electrical nerve stimulation (TENS) is not reasonable and necessary for the 
treatment of chronic low-back pain (CLBP). You can find this information in the Centers for Medicare and 
Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, Medicare National Coverage 
Determinations (NCD) Manual, Section 160.27. 
 
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 pharmacogenomic (PGx) tests are indicated when medications are being considered for use 
(or already being administered) that are medically necessary, appropriate, and approved for use in the patient's 
condition and are known to have a gene(s)-drug interaction that has been demonstrated to be clinically 
actionable as defined by the Food & Drug Administration (FDA) (PGx information required for safe drug 
administration) or Clinical Pharmacogenetic Implementation Consortium (CPIC) guidelines (category A and 
B). The clinical record must clearly show the use of or intent to prescribe a drug that has known drug-gene 
interactions that require a PGx test to be ordered to define the safe use of that drug in that patient. You can find 
these rules in Local Coverage Determination (LCD) MolDX: Pharmacogenomics Testing (L38337). 
 
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). 
 
The rules say that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments 
(CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following requirements 
are met: 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
You can find this rule in National Coverage Determination (NCD) Next Generation Sequencing (NGS) 90.2. 
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 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 Grievance Manual, Section 50.12.1. 
 
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 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 pontics and 
retainer crowns but are limited to 1 procedure code every 5 calendar years. The core buildup is not covered by 
the Plan's dental benefits. You can find this information on pages 63 to 65 of the Plans 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 continued coverage of a PAP device (E0470 or E0601) beyond the first three months of 
therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the 
treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from 
PAP therapy. 
For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is 
demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
Adherence to therapy is defined as use of PAP 4 hours per night on 70% of nights during a consecutive thirty 
(30) day period anytime during the first three (3) months of initial usage. 
 
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as 
not reasonable and necessary. You can find this rule at Local Coverage Determination (LCD) L33718: Positive 
Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (eff. 9/27/21). 
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 physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. You can find this in the Centers for Medicare 
and Medicaid Service, Internet-Only Manual, Publication Number 100-04, Medicare Claims Processing 
Manual, Chapter 12, Section 30.6.5. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
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, 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 pages 36-38 of the Plan's 2023 
Evidence of Coverage (EOC).