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 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 non-covered services include: 
1. Blanket Orders 
2. Reflex definitive urine drug testing (UDT) is not reasonable and necessary when presumptive testing is 
performed at point of care because the physician may have sufficient information to manage the patient. 
If the clinician is not satisfied, he/she must determine the clinical appropriateness of and order specific 
subsequent definitive testing (e.g., the patient admits to using a particular drug, or the IA cut-off is set at 
such a point that is sufficiently low that the physician is satisfied with the presumptive test result). 
3. Routine standing orders for all patients in a physician's practice are not reasonable and necessary. 

You can find the rules in Local Coverage Determination (LCD) Controlled Substance Monitoring and Drugs of 
Abuse Testing L36393. 
 
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 coverage for TEE is considered medically reasonable and necessary in the following 
situations: 

1. When TTE has not established the diagnosis, or 
2. In a patient where TTE is felt not to give adequate information (e.g., as in extreme obesity, severe 
chronic obstructive pulmonary disease [COPD], chest deformity, inadequate or incomplete visualization 
of the left atrium and left atrial appendage in patients with prosthetic material, and inadequate 
visualization of the atrial septum for making the diagnosis of patient foramen ovale). 
A TEE may be performed as an initial test in the following scenarios: 
1. There is suspected acute aortic pathology including dissection or transection; 
2. For guidance of percutaneous non-coronary cardiac interventions (e.g., radiofrequency ablation of atrial 
arrhythmias, alcohol septal ablation, percutaneous mitral or aortic valvuloplasty, atrial occluder device 
deployment, or management of VAD prior to heart transplantation); 
3. To determine the mechanism of valve regurgitation and/or suitability for valve repair; 
4. To diagnose or subsequently manage suspected endocarditis with moderate or high pre-test probability 
of the disease; 
5. Persistent fever with an intracardiac device; or 
6. For clinical decision making, including possible cardioversion or radiofrequency ablation of atrial 
flutter/fibrillation when anticoagulation alone is not already planned. 

You can find this rule at Local Coverage Determination (LCD) L35016: Transesophageal Echocardiography 
(TEE) (eff. 10/17/19). 
 
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 PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) is covered in 
patients with BOTH the following: 
 
1. Inclusion criteria (ALL are required): Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral 
compression fracture (VCF) (T1  L5) by recent (within 30 days) advanced imaging (bone marrow edema on 
magnetic resonance imaging (MRI) or bone-scan/single photon emission computed tomography 
(SPECT)/computed tomography (CT) uptake) 
 
2: Symptomatic (ONE): Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score = 8)4-7, Non-hospitalized with moderate-to-severe pain (NRS or VAS =5) despite optimal 
non-surgical management (NSM)10, Worsening pain, Stable-to-improved pain (but NRS or VAS still =5) (with 
= 2 of the following): Progression of vertebral body height loss > 25% vertebral body height reduction 
Kyphotic deformity or Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire 
(RDQ) >17) 
 
This information is found in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38737). 
 
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 page 15 of the 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
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: 
Nationally Covered Indications 
Effective July 15, 1996, adult liver transplantation when performed on beneficiaries with end- stage liver 
disease other than hepatitis B or malignancies is covered under Medicare when performed in a facility which is 
approved by the Centers for Medicare & Medicaid Services (CMS) as meeting institutional coverage criteria. 
Effective December 10, 1999, adult liver transplantation when performed on beneficiaries with end-stage liver 
disease other than malignancies is covered under Medicare when performed in a facility which is approved by 
CMS as meeting institutional coverage criteria. 
Effective September 1, 2001, Medicare covers adult liver transplantation for hepatocellular carcinoma when the 
following conditions are met: 
 The patient is not a candidate for subtotal liver resection; 
 The patients tumor(s) is less than or equal to 5 cm in diameter; 
 There is no macrovascular involvement; 
 There is no identifiable extrahepatic spread of tumor to surrounding lymph nodes, lungs, abdominal 
organs or bone; and, 
 The transplant is furnished in a facility that is approved by CMS as meeting institutional coverage 
criteria for liver transplants (see 65 FR 15006). 
Effective June 21, 2012, Medicare Administrative Contractors acting within their respective jurisdictions may 
determine coverage of adult liver transplantation for the following malignancies: (1) extrahepatic unresectable 
cholangiocarcinoma (CCA); (2) liver metastases due to a neuroendocrine tumor (NET); and (3) 
hemangioendothelioma (HAE). 
 1. Follow-Up Care 
Follow-up care or re-transplantation required as a result of a covered liver transplant is covered, provided such 
services are otherwise reasonable and necessary. Follow-up care is also covered for patients who have been 
discharged from a hospital after receiving non-covered liver transplant. Coverage for follow-up care is for 
items and services that are reasonable and necessary as determined by Medicare guidelines. 
2. Immunosuppressive Drugs 
See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50.5.1 
and the Medicare Claims Processing Manual, Chapter 17, Drugs and Biologicals, 80.3. 
C. Nationally Non-Covered Indications 
Adult liver transplantation for other malignancies remains excluded from coverage. 
You can find this rule at the Medicare National Coverage Determination (NCD) 260.1: Adult Liver 
Transplantation. 
 
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 does not pay for over the counter (OTC) items, including self-administered 
COVID-19 tests. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2. 
 
The rules say that Medicare does not generally cover or pay for over the counter products. The demonstration 
that allowed Medicare to offer coverage for COVID-19 over-the-counter tests at no cost ended on May 11, 
2023. You can find this information in the Coverage for COVID-19 Tests Article at Coverage for COVID-19 
Tests (cms.gov). 
 
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 does not pay for over the counter (OTC) items, including self-administered 
COVID-19 tests. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2.  
 
The rules say that Medicare does not generally cover or pay for over-the-counter products. The demonstration 
that allowed Medicare to offer coverage for COVID-19 over the counter tests at no cost ended on May 11, 
2023. You can find this information in the Coverage for COVID-19 Tests Article at Coverage for COVID-19 
Tests (cms.gov). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare & Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(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.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules also say that if a procedure has a global period of 000 or 010 days, it is defined as a minor surgical 
procedure. (Osteopathic manipulative therapy and chiropractic manipulative therapy have global periods of 
000.) In general, evaluation and management (E&M) services on the same date of service as the minor surgical 
procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is 
included in the payment for the minor surgical procedure and shall not be reported separately as an E&M 
service. However, a significant and separately identifiable E&M service unrelated to the decision to perform 
the minor surgical procedure is separately reportable with modifier -25. The E&M service and minor surgical 
procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the 
same rules for reporting E&M services apply. The fact that the patient is new to the provider/supplier is not 
sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct Coding 
Initiative Policy Manual for Medicare Services, Chapter 11(U). 
 
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 55 of the Plans 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 section 1886(j) of the Social Security Act (the Act) provides for the implementation of a 
prospective payment system (PPS) under Medicare for inpatient hospital services furnished by a rehabilitation 
hospital or a rehabilitation unit of a hospital (referred to as an inpatient rehabilitation facility (IRF)). Effective 
with cost reporting periods beginning on or after January 1, 2002, IRFs are required to report billing data with a 
specific revenue code and a Health Insurance PPS (HIPPS) Rate Code. The revenue code, 0024, is used in 
conjunction with the HIPPS Rate Code to identify the case-mix group (CMG) payment classification for the 
hospital stay. You can find this in the Centers for Medicare & Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.1 and 140.3. 
 
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 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 genes not identified as having actionable use are not considered reasonable and necessary. 
The algorithms employed in combinatorial testing are also not currently considered reasonable and necessary 
components of multi-gene testing. Pharmacogenomics (PGx) testing is not covered when a treating clinician is 
not considering treatment with a medication that has an actionable drug-gene interaction, or when the use of a 
medication with a drug-gene interaction is not reasonable and necessary. You can find these rules in Local 
Coverage Determination (LCD) MolDX: Pharmacogenomics Testing L38394. 
 
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 40% coinsurance for out-of-network breast cancer screening.  You can 
find this information on page(s) 46 of the Plan's 2023 Evidence of Coverage.