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 date of service (DOS) policy for either a clinical laboratory test or the technical component of physician
pathology service is as follows: General Rule: The DOS of the test/service must be the date the specimen was
collected. Variation: If a specimen is collected over a period that spans two calendar days, then the DOS must
be the date the collection ended. Exceptions: The following three exceptions apply to the DOS policy for either
a clinical laboratory test or the technical component of physician pathology service: A. DOS for Tests/Services
Performed on Stored Specimens: In the case of a test/service performed on a stored specimen, if a specimen
was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service
must be the date the test/service was performed only if: - The test/service is ordered by the patient's physician
at least 14 days following the date of the patient's discharge from the hospital; - The specimen was collected
while the patient was undergoing a hospital surgical procedure; - It would be medically inappropriate to have
collected the sample other than during the hospital procedure for which the patient was admitted; - The results
of the test/service do not guide treatment provided during the hospital stay; and - The test/service was
reasonable and medically necessary for treatment of an illness. If the specimen was stored for more than 30
calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service
must be the date the specimen was obtained from storage. You can find this in the Medicare Claims Processing
Manual Chapter 16 under Laboratory Services, section 40.8, Date of Service (DOS) for Clinical Laboratory
and Pathology Specimens.
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).
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 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. This benefit includes the 
requested item or service but is limited to once per 60 Months. You can find this information on pages 94 to 
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 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 date of service (DOS) policy for either a clinical laboratory test or the technical component of physician
pathology service is as follows: General Rule: The DOS of the test/service must be the date the specimen was
collected. Variation: If a specimen is collected over a period that spans two calendar days, then the DOS must
be the date the collection ended. Exceptions: The following three exceptions apply to the DOS policy for either
a clinical laboratory test or the technical component of physician pathology service: A. DOS for Tests/Services
Performed on Stored Specimens: In the case of a test/service performed on a stored specimen, if a specimen
was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service
must be the date the test/service was performed only if: - The test/service is ordered by the patient's physician
at least 14 days following the date of the patient's discharge from the hospital; - The specimen was collected
while the patient was undergoing a hospital surgical procedure; - It would be medically inappropriate to have
collected the sample other than during the hospital procedure for which the patient was admitted; - The results
of the test/service do not guide treatment provided during the hospital stay; and - The test/service was
reasonable and medically necessary for treatment of an illness. If the specimen was stored for more than 30
calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service
must be the date the specimen was obtained from storage. You can find this in the Medicare Claims Processing
Manual Chapter 16 under Laboratory Services, section 40.8, Date of Service (DOS) for Clinical Laboratory
and Pathology Specimens.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 56-60 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 a $10 copayment for Office visits. You can find this information on 
page(s) 105 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 Effective for dates of service specified below, the Centers for Medicare & Medicaid Services 
(CMS) has determined that PILD will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for 
beneficiaries with LSS who are enrolled in an approved clinical study that meets the criteria below: 
 
Effective for services performed on or after December 7, 2016, CMS will cover through a prospective, 
longitudinal study PILD procedures using an FDA-approved/cleared device that completed a CMS-approved 
randomized control trial (RCT). 
 
You can find this information in the National Coverage Determination (NCD) 150.13  Percutaneous image-
guided Lumbar Decompression for Spinal Stenosis. 
 
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.
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 quantitative calcium scoring is not a covered service and will be denied as not medically 
necessary. Calcium scoring reported in isolation is considered a screening service. When performed in 
association with CT angiography, there is neither separate nor additional included reimbursement for the 
calcium scoring. You can find this rule in Local Coverage Determination (LCD): Cardiac Computed 
Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) (L33559). 
 
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 is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which 
the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 
Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood).  A physician's order 
and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity 
of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific 
event cannot be identified.  Replacement of equipment due to irreparable wear takes into consideration the 
reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual, 
Chapter 15, Section 100.2. 
 
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 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 definitive drug testing is indicated when the results of the screen are presumptively positive. 
Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
This test may also be used, when the coverage criteria of the policy are met and there is no presumptive test 
available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids. You 
can find this rule in the Local Coverage Determination for Drug Testing, L34645.  
 
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 there is covered for parenteral iron in iron deficiency anemia (IDA): 
1. When oral supplementation has been tried and the patient has demonstrated significant gastrointestinal 
distress whereas compliance with an oral regimen is no longer feasible. This includes patients with chronic 
kidney disease who are not yet requiring dialysis; 
2. In beneficiaries who have a pathological or anatomical presentation where oral iron is unlikely to be 
absorbed or may further cause exacerbation of the underlying gastrointestinal disorder. This primarily includes 
use in patients with proven inflammatory bowel disease, short bowel/short gut syndrome and following gastric 
bypass surgery. This includes patients with a known abnormally high hepcidin level and those with iron 
refractory iron deficiency anemia; 
3. Beneficiaries with chemotherapy induced anemia when an erythropoietin stimulating agent is being used in 
accordance with Medicare guidelines and where oral supplementation is unlikely to be sufficient or the anemia 
is so severe as to require more urgent iron supplementation. If treating anemia exacerbated cardiac disease one 
should give precedence to transfusions in the acute setting; 
4. In a beneficiary who has ongoing iron losses (such as severe menorrhagia, Rendu-Osler-Weber disease) 
where oral iron replenishment is inadequate or contraindicated only until definitive intervention, when 
available, is successfully undertaken. 
5. Use in the pregnant beneficiary when iron stores are depleted such that the mother and/or the fetus are at risk 
of adverse outcomes and oral iron replenishment is either not tolerated or the anemia is of such severity as to 
require more immediate replenishment. Additionally, use in the peripartum period may be indicated when 
intra/post-partum hemorrhage is severe and by administering parenteral iron a transfusion may be avoided. This 
indication does not replace the strong consideration for transfusions when the hemorrhage is potentially life 
threatening. 
 
You can find this rule in the Local Coverage Article (LCA) - Parenteral Iron Administration Coverage in Non-
Dialysis Usage (A55734) - Effective January 15, 2018. 
 
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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made 
based upon the specifics of each persons medical condition. There must be enough detailed information in the 
medical record to justify the treatment selected. 
 
Products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-level 
PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in 
the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in 
this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP 
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions 
described in this RAD policy will be denied as not reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 enrollees must pay a $325 copayment per day for days 1 to 5 of an inpatient stay.
You can find this information on page 96 of the Plan's 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 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 and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
The rules say that all line items for the same beneficiary, same NPI, and same date of service shall be subject to 
NCCI Procedure-to-Procedure (PTP) edits. If the correct coding modifier indicator (CCMI) of a PTP edit is 
"0", the Column Two code is not eligible for payment even if an NCCI PTP-associated modifier is 
appropriately appended to one of the codes. If the CCMI of a PTP edit is "1", the edit may be bypassed, and the 
Column Two code of the edit may be eligible for payment if an NCCI PTP-associated modifier is appropriately 
appended to one of the 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 23, Section 20.9.1.1 
 
The rules say that providers performing validity testing on urine specimens utilized for drug testing should not 
separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, 
creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not 
separately billed. You can find this information in the National Correct Coding Initiative (NCCI) Policy 
Manual, Chapter X, page X-7. 
 
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 to be eligible for coverage of home blood glucose monitors and related accessories and 
supplies, the beneficiary must meet both of the following basic criteria (1)  (2): 
1. The beneficiary has diabetes (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable 
diagnoses); and 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or the beneficiarys caregiver) has 
sufficient training using the particular device prescribed as evidenced by providing a prescription for the 
appropriate supplies and frequency of blood glucose testing. 
 
For all glucose monitors and related accessories and supplies, if the basic coverage criteria (1)-(2) are not met, 
the item(s) will be denied as not reasonable and necessary. You can find this information in the Local Coverage 
Determination (LCD): Glucose Monitors (L33822). 
 
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.