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 state that neurogenic disorders can be distinguishable from myopathic disorders by a carefully 
performed EMG. For example, both polymyositis and ALS produce manifest weakness. The former carries a 
very different prognosis and treatment than the latter. An EMG is very valuable in making this distinction. 
Similarly, classification of nerve trauma into axonal vs. demyelinating categories, with corresponding 
differences in prognoses, are possible with EMG. Below is a list of common disorders where an EMG, in 
tandem with a properly conducted NCS, will be helpful in diagnosis: 
1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions. 
2. Radiculopathy - cervical, lumbosacral. 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary. 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies. 
5. Plexopathy - idiopathic, trauma, infiltration. 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here. 
7. At times, immediately prior to botulinum toxin injection, for localization. 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or 
chemodenervation. 
There may be other instances, not detailed here, where EMG may be of use. 
The necessity and reasonableness of the following uses of EMG studies have not been established: 
 exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions 
 definitive diagnostic conclusions based on paraspinal EMG in regions bearing scars of past surgeries 
(e.g., previous laminectomies) 
 pattern-setting limited limb muscle examinations, without paraspinal muscle testing for a diagnosis of 
radiculopathy 
 EMG testing shortly after trauma, before EMG abnormalities would have reasonably had time to 
develop 
 surface and macro EMGs 
 multiple uses of EMG in the same patient at the same location of the same limb for the purpose of 
optimizing botulinum toxin injections. 
You can find this information in Local Coverage Determination (LCD): Nerve Conduction Studies and 
Electromyography (L35048). 
 
The rules provide a list of acceptable diagnosis codes which support medical necessity. Code H93.3X2 is not included in this list. You can find this information in Local Coverage Article (LCA): Billing and Coding: 
Nerve Conduction Studies and Electromyography (A56619).  
 
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 $250 for each one-way Medicare-covered ambulance transport. You can 
find this information on page 70 of the Plan's 2022 Evidence of Coverage (EOC). The Plan contract also says 
that for each in-network Medicare-covered hospital admission/stay you must pay $325 per day for days 1 to 6; 
$0 for additional hospital days. You can find this information on page 91 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 state that field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative 
periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with 
entries of 000, 010, 090, and, sometimes, YYY. Codes with 090 in Field 16 are major surgeries. Codes with 
000 or 010 are either minor surgical procedures or endoscopies. The Medicare approved amount for these 
procedures includes payment for the following services related to the surgery when furnished by the physician 
who performs the surgery. 
 
Modifiers were established to simplify billing for visits and other procedures which are furnished during the 
postoperative period of a surgical procedure, but which are not included in the payment for the surgical 
procedure. 
 
Modifier -24 reports an unrelated evaluation and management service by same physician during a 
postoperative period. The physician may need to indicate that an evaluation and management service was 
performed during the postoperative period of an unrelated procedure. This circumstance is reported by adding 
the modifier -24 to the appropriate level of evaluation and management service. Services submitted with the 
-24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. A 
diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable 
documentation. 
 
You can find this information 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 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 repeat epidural steroid injection (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. 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 information in Local Coverage Determination (LCD): Epidural Steroid 
Injection for Pain Management (L39015). 
 
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 rules say 
that a repeat epidural steroid injection (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. 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 information in Local Coverage Determination (LCD): Epidural Steroid Injection for Pain 
Management (L39015).
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 ConfirmMDx is covered under the following conditions: 
1. Males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 
months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors, 
and 
2. The previous negative prostate biopsy must have collected a minimum of 8 tissue cores (but not have 
received a saturation biopsy of greater than 24 tissue cores) and remaining FFPE tissue from all cores is 
available for testing, and 
3. Minimum tissue volume criteria of 20 microns of prostate biopsy core tissue is available (40 microns 
preferable), and 
4. Previous biopsy histology does not include a prior diagnosis of prostate cancer or cellular atypia 
suspicious for cancer (but may include the presence of high-grade prostatic intraepithelial neoplasia 
(HGPIN), proliferative inflammatory atrophy (PIA), or glandular inflammation), and 
5. Patient is not being managed by active surveillance for low stage prostate cancer, and 
6. Tissue was extracted using standard patterned biopsy core extraction (and not transurethral resection of 
the prostate (TURP)), and 
7. Patient has not been previously tested by ConfirmMDx from the same biopsy samples or similar 
molecular test. 
You can find this rule in the Local Coverage Determination (LCD): ConfirmMDx Epigenetic Molecular Assay 
(L36327). 
 
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 for these items of DME, A/B MACs (HHH) and DME MACs pay the fee schedule amounts 
on a monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, 
the beneficiary is given a purchase option (see 30.5.2). If the purchase option is exercised, A/B MACs (HHH) 
and DME MACs continue to pay rental fees not to exceed a period of continuous use of 13 months and 
ownership of the equipment passes to the beneficiary. If the purchase option is not exercised, A/B MACs 
(HHH) and DME MACs continue to pay rental fees until the 15-month cap is reached and ownership of the 
equipment remains with the supplier (see 30.5.4). In the case of electric wheelchairs only, the beneficiary 
must be given a purchase option at the time the equipment is first provided (see 30.5.3). You can find this 
information in the Medicare Claims Processing Manual Chapter 20, Durable Medical Equipment, Prosthesis, 
Orthotics and Supplies 30.5 - Capped Rental Items. 
 
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 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. You can 
find this information in the Centers for Medicare and Medicaid Services (CMS), 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 treatment for LUTS/BPH treatment will be considered reasonable and necessary when 
performed ONCE in patients with the following: 
1. Indications including ALL of the following:  
a. Age 80 
b. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS) 
c. Persistent moderate to severe symptoms despite maximal medical management 
including ALL of the following: 
i. International Prostate Symptom Score (IPSS) 12 
ii. Maximum urinary flow rate (Qmax) of 15 mL/s (voided volume greater than 125 cc) 
iii. Failure, contraindication or intolerance to at least three months of conventional medical 
therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
      2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary.  
The rules say that the following are considered not reasonable and necessary: 
1. Body mass index  42kg/m2 
2. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines) or a 
prostate specific antigen (PSA) >10 ng/mL unless the patient has had a negative prostate biopsy within 
the last 6 months. 
3. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum 
4. Active urinary tract or systemic infection 
5. Treatment for chronic prostatitis 
6. Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 
7. Damaged external urinary sphincter 
8. Known allergy to device materials 
9. Inability to safely stop anticoagulants or antiplatelet agents preoperatively. You can find these rules in the Local Coverage Determination (LCD) Transurethral Waterjet Ablation of the 
Prostate L38705. 
 
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 65 of the 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 state that Medicare shall pay for up to three (3) FDG PET scans when used to guide subsequent 
management of anti-tumor treatment strategy (modifier PS) after completion of initial anti-cancer therapy 
(modifier PI) for the exact same cancer diagnosis. Coverage of any additional FDG PET scans (that is, beyond 
3) used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-tumor 
therapy for the same cancer diagnosis will be determined on a case-by-case basis. A different cancer diagnosis 
whether submitted with a PI or a PS modifier will begin the count of one initial and three subsequent FDG PET 
scans. Providers are directed to a list of appropriate PET oncologic imaging diagnosis codes. You can find this 
information in the Medicare Claims Processing Manual, Chapter 13, Section 60.16. 
 
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 standby services are not payable to physicians. Physicians may not bill Medicare or 
beneficiaries for standby services. Payment for standby services is included in the Part A payment to the 
facility. Such services are a part of hospital costs to provide quality care. If hospitals pay physicians for standby 
services, such services are part of hospital costs to provide quality care. You can find this rule at the Medicare 
Claims Processing Manual, Chapter 12, Section 30.6.15.3. 
 
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.
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 covered items include, but are not limited to: wheelchairs, crutches, powered mattress 
systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV, infusion pumps, speech 
generating devices, oxygen equipment, nebulizers, and walkers. The Plan covers all medically necessary DME 
covered by Original Medicare. You can find this information on page 4-18 of the Plan's 2022 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that repeat epidural steroid injection 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. You can find this rule in the Local 
Coverage Determination (LCD) - Epidural Steroid Injections for Pain Management (L39054) - Effective June 
30, 2022. 
 
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 also say that for transitional care management (TCM) services, after inpatient discharge, the patient 
must return to their community setting. These could include a home, domiciliary (such as a group home or 
boarding house), nursing facility, or assisted living facility. You can find this information in the Medicare 
Learning Network Booklet: Transitional Care Management Services. 
 
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.