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 $350 copayment per day for other Medicare-covered diagnostic radiology 
services that are not ultrasounds. You will only pay one copayment per day even if multiple diagnostic 
radiology services are performed. You can find this information on page 101 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 Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 also says that hearing aids purchased outside the Plans hearing aid network are not covered. The Plan 
contract also says that hearing aid accessories and optional services are available for you to buy, but they are 
not covered by the Plan. You can find this information on pages 4-22 to 4-23 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 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). 
 
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 also says that knee scooters are not a covered item. You can find this information on page 119 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 the following sections cover the codes used to describe PET scans and the diagnoses that 
may justify use of the scan if all other Medicare requirements for coverage are met. Details of Medicare 
coverage requirements are NOT quoted in this article. Providers should familiarize themselves with the NCD 
  
  (IOM Medicare National Coverage Determination (NCD) Manual, Publication 100-03, Chapter 1, Part 4, 
Section 220.6.1, 220.6.8, 220.6.9, 220.6.13, 220.6.17, 220.6.19 and 220.6.20) on PET Scans, which is the 
source of all information in this article. 
 
The following diagnoses are applicable to piflufolastat F 18 (PYLARIFY) injections when billed with 78811, 
78812, 78813, 78814, 78815 or 78816 with the PS modifier. Use A9595 to bill for this service effective 
01/01/2022. For providers to be paid appropriately, A9595 must be billed per mCi effective 01/01/2022. 
 
When A9595 is billed in the OPPS setting or in Part B outpatient setting, the diagnosis codes below will be 
paid, effective 01/01/2022. 
 
NOTE: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a 
diagnosis code from the list of covered C, D, or R diagnosis codes. 
 
Effective 09/10/2021, the NCCN Guidelines have been updated to allow PSMA-PET/CT or PSMA-
PET/MRI with piflufolastat PSMA to be considered effective for initial staging of bone and soft 
tissues imaging with the use of the PI modifier, or with suspected recurrence based on elevated serum 
prostate-specific antigen (PSA) level. Providers must amend the KX modifier on the claim to attest that the 
use of the PI modifier is per NCCN Guidelines 
 
You can find this information in the Local Coverage Article Billing and Coding Billing and Coding: Positron 
Emission Tomography Scans Coverage A54666. 
 
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 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). 
 
Subsequent hospital care services are limited to one telehealth visit every 3 days. The frequency limit of the 
benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial 
or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes. Similarly, subsequent 
nursing facility care services are limited to one telehealth visit every 30 days. Beginning with dates of service 
on and after January 1, 2021, the limit for nursing facility care services is one telehealth visit every 14 days. 
Furthermore, subsequent nursing facility care services reported for a Federally mandated periodic visit under 
42 CFR 483.40(c) may not be furnished through telehealth. The frequency limit of the benefit is not intended to 
apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient 
telehealth consultations using the applicable HCPCS G-codes. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Section 190.3.5. 
 
The rules say for subsequent nursing facility care services, the patient's admitting physician or non-physician 
practitioner is limited to one telehealth visit every 14 days for the following codes when billed with the GT or 
GQ modifier or Place of Service (POS) code 02, effective for claims with dates of services on or after January 
1, 2021, that are processed on or after July 6, 2021: 99307, 99308, 99309, and 99310. You can find this rule in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Transmittal 10716. 
 
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. 
 
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 also says that kake sure your doctors and DME suppliers are enrolled in Medicare. Its important to 
ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, 
they must accept assignment (which means, they can charge you only the coinsurance and Part B deductible for 
the Medicare-approved amount). If suppliers arent participating and dont accept assignment, theres no limit 
on the amount they can charge you. Medicare wont pay claims for doctors or suppliers who arent enrolled in 
Medicare. You can find this information on page 40 of the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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. 
 
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 the Medicare Physician's Fee Schedule Database (MPFSDB) Code of N is for Non-covered 
service. These codes are carried on the HCPCS tape as noncovered services. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual Chapter 23, Section 30.2.2. 
 
The rules state that the Medicare approved amount for global surgery procedures includes payment for the 
following services related to the surgery when furnished by the physician who performs the surgery. 
 
 
- Preoperative Visits  - Intra-operative Services  
- Complications Following Surgery  
- Postoperative Visits  
- Postsurgical Pain Management  
- Supplies  
- Miscellaneous Services 
 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, 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 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 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. 
 
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 also says that while you can get your care from an out-of-network provider, the provider must be 
eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out of 
or been excluded or precluded from the Medicare Program. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your 
provider before receiving services to confirm that they are eligible to participate in Medicare. You can find this 
information on page 3-3 to 3-4 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 moderate persistent asthma is defined by the National Heart, Lung, and Blood Institute 
(NHLBI) as: 
 
    Daily symptoms 
    Daily use of inhaled short-acting beta 2-agonist 
    Some limitation with normal activity 
    Exacerbations requiring oral systemic corticosterioids > 2/year 
    Nighttime symptoms greater than 1 time a week but not nightly 
    FEV 1 >60% but <80% predicted 
    FEF 1/FVC reduced 5% 
 
Severe persistent asthma 
 
Severe persistent asthma is defined by the National Heart, Lung, and Blood Institute (NHLBI) as: 
 
    Symptoms throughout the day 
    Use of inhaled short-acting beta 2-agonist several times per day 
    Extremely limited normal activity 
    Exacerbations requiring oral systemic corticosterioids > 2/year 
    Nighttime symptoms often 7x/week 
    FEV 1 <60% predicted 
    FEV 1/FVC reduced >5% 
 
NHLBI normal ranges by age for FEV 1/FVC 
 
    8-19 years of age  85%; 
    20-39 years of age  80%; 
    40-59 years of age  75%; 
    60-80 years of age  70%. 
 
The presence of one of these features of severity (moderate or severe) is sufficient to place a patient in that 
category. These clinical features are based on pre-treatment symptoms and measurements. 
 Because of the chance of anaphylaxis with omalizumab, patients should receive omalizumab treatment in a 
doctor's office or clinic setting and be observed for an appropriate period of time after each treatment. 
Omalizumab should only be administered in a healthcare setting by healthcare providers prepared to manage 
anaphylaxis that can be life-threatening. 
 
Omalizumab has not been shown to alleviate asthma exacerbations acutely and should not be used for the 
treatment of acute bronchospasm or status asthmaticus. 
 
Utilization: 
 
Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). 
When services are performed in excess of established parameters, they may be subject to review for medical 
necessity. 
 
Omalizumab is covered when the drug is administered by a physician or incident to a physicians service in a 
clinic or office setting. 
 
Omalizumab is not covered if self-administered by the patient. 
 
You can find this information in the Local Coverage Article Billing and Coding Billing and Coding: 
Omalizumab A52448. 
 
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 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 durable medical equipment and related supplies. 
You can find this information on pages 4-18 to 4-19 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 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. The Plan contract says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. The contract also says that intraoral x-rays are limited to 1 procedure code per calendar year. You 
can find this information on pages 93 and 94 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 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 $45 copayment for podiatry services. You can find this information on 
page 112 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 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 $230 per day for days 1 to 5 for inpatient mental health care. You can find 
this information on page 85 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 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 includes a list of covered supplemental dental services. Caries preventive medicament application 
(D1355) is not included on this list and is not a covered supplemental benefit. You can find this information on 
pages 63 and 94 of the Plans 2022 Evidence of Coverage (EOC).