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 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 $300 copayment per visit for outpatient diagnostic and therapeutic 
services and supplies, including MRI's. You can find this information on page 82 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 the Plans goal is to process all claims at initial submission. Before the Plan can process a claim, 
it must be a "clean" or complete claim submission, which includes the following claim elements when 
applicable: 
 
Patients' Network Health identification number 
Patients' first and last name 
Patients' date of birth (month, day, and year) 
Subscribers' full name and address 
Patients' signature or indication of signature on file 
Standard International Classification of Diseases (ICD-10) Codes 
Dates of Service 
Place of service/bill type (Facility) 
Standard Current Procedural Terminology (CPT) code sets 
Standard Healthcare Common Procedure Coding System (HCPC) code sets 
Revenue Codes (Facility) 
Modifiers 
Diagnosis Related Group (DRG) Codes 
Resource Utilization Groups (RUG) codes (when applicable) 
Individual charges for each billed services 
Units of service 
Providers' National Provider Identification (NPI) Number 
     * Individual Physician NPI required in 24j and 33a 
     * Clinic NPI required in 32a and 33a 
Provider Tax Identification Number (TIN) 
 Taxonomy code (required for Medicare claims only) 
      * Box 24j & 33b for Physician/HCFA claims 
      * Box 81cc for Facility/UB04 claims 
Facility/provider name, address, and telephone number 
Billing name, address, and telephone number 
Accident state 
Providers' signature 
Primary carrier Explanation of Benefits (EOB) when Network Health is the secondary payer 
For miscellaneous circumstances (corrected claim, covering MD, and unlisted CPT/HCPC code), please 
indicate explanation 
Miscellaneous drug codes require the National Drug Code (NDC) on the corresponding claim line 
 
If any of the above information is missing from the claim, Network Health will not be able to process your 
claim. If you have questions regarding required fields on a claim, please contact Network Health's Member 
Experience Department. 
 
You can find these rules in the Claims Submission Policy n05659. 
 
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 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 in the Local Coverage Determination (LCD): Oral Appliances 
for Obstructive Sleep Apnea (L33611). 
 
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 Epidural steroid injection (ESI) will be considered medically reasonable and necessary when 
the following three (3) requirements are met: 
 History, physical examination, and concordant radiological image-based diagnostic testing supporting 
one of the following: 
 
 Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis; OR 
 Post-laminectomy syndrome; OR 
 Acute herpes zoster associated pain 
AND 
 Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality 
of life or function. An objective pain scale or functional assessment must be performed at baseline 
(prior to interventions). The same scale must be repeated at each follow-up for assessment of response. 
AND 
 Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative 
care or acute herpes zoster refractory to conservative management where a four (4) week wait is not 
required. 
 
You can find this rule in the Local Coverage Determination for Epidural Steroid Injections, L39036.  
 
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 pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners. 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 to qualify for portable oxygen, the patient must meet the criteria for home oxygen. Patients 
who are mobile in the home and would benefit from the use of portable oxygen in the home, may qualify for 
coverage of a portable oxygen system either by itself, or to use in addition to a stationary oxygen system. 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 240.2 (D). 
 
The rules say that oxygen is coverable when medically necessary for patients with acute or chronic conditions, 
short- or long- term, when the patient exhibits hypoxemia. Patients exhibiting hypoxemia are defined using the 
clinical criteria below.  
 
1. Arterial PO2 (partial pressure of oxygen) at or below 55 mm Hg or arterial O2 (oxygen) saturation at or 
below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for patients who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
In reviewing the arterial PO2 levels and the arterial oxygen saturation percentages specified above, variations 
in oxygen measurements that may result from such factors as the patient's age, the patients skin pigmentation, 
the altitude level, or the patient's decreased oxygen carrying capacity, must be taken into account.  
 
For patients who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when 
medically reasonable and necessary for patients who do not have a non-covered indication.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Sections 240.2. 
 
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 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 20% coinsurance for Medicare Part B drugs. You can find this 
information on page 39 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 providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, 30.2.2. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare rules say that orally administered enteral nutrition products, related supplies and equipment will be 
denied as non-covered, no benefit. You can find this information in Medicare Local Coverage Article: Eternal 
Nutrition (A58833). 
 
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 accessories used with beneficiary-owned oxygen equipment will be denied as non-covered. 
You can find this rule in Local Coverage Article Oxygen and Oxygen Equipment - Policy Article A52514. 
 
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 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 routine transportation for up to fifty-two (52) trips every year. You can find this information 
in Chapter 4 on page 116 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 a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and 
necessary. You can find this information in Medicare's Local Coverage Determination (LCD): Cold Therapy 
(L33735). 
 
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 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 routine transportation for up to thirty (30) trips every year. You can find this information in 
Chapter 4 on page 114 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 state that concentric adjustable torsion style mechanisms used to assist knee joint extension are coded 
as L2999 and are covered for beneficiaries who require knee extension assist in the absence of any co-existing 
joint contracture. 
 
Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are 
coded as L2999 and are covered for beneficiaries who require ankle plantar or dorsiflexion assist in the absence 
of any co-existing joint contracture. 
 
Claims for devices incorporating concentric adjustable torsion style mechanisms used for the treatment of any 
joint contracture and coded as L2999 will be denied as incorrect coding. 
 
You can find more information in Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot 
Orthosis (L33686). 
 
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 pay for durable medical equipment (DME) that is mainly used to serve a
medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment
that are clearly used for medical purposes. You can find these rules in the Centers for Medicare and Medicaid
Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section
110.1.
The rules also say that prosthetic devices (other than dental) which replace all or part of an internal body organ
(including contiguous tissue), or replace all or part of the function of a permanently inoperative or
malfunctioning internal body organ are covered when furnished on a physician's order. You can find this in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit
Policy Manual, Chapter 15, Section 120.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that for wigs, the Plan covers a maximum of $500 per calendar year. If you choose a
participating provider, you have the benefit of $500 per calendar year applied at the time of service and would
be responsible to pay for any remaining balance. You can see this on page 118 of the Plans 2021 Evidence of
Coverage.