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 Program reimbursement for HBO therapy will be limited to that which is administered in a 
chamber (including the one man unit) and is limited to the following conditions: 
1. Acute carbon monoxide intoxication, 
2. Decompression illness, 
3. Gas embolism, 
4. Gas gangrene, 
5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in 
combination with accepted standard therapeutic measures when loss of function, limb, or life is 
threatened. 
6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an 
adjunctive treatment when loss of function, limb, or life is threatened. 
7. Progressive necrotizing infections (necrotizing fasciitis), 
8. Acute peripheral arterial insufficiency, 
9. Preparation and preservation of compromised skin grafts (not for primary management of wounds), 
10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, 
11. Osteoradionecrosis as an adjunct to conventional treatment, 
12. Soft tissue radionecrosis as an adjunct to conventional treatment, 
13. Cyanide poisoning, 
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to 
antibiotics and surgical treatment, 
15. Diabetic wounds of the lower extremities in patients who meet the following three criteria:  
 . Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; 
a. Patient has a wound classified as Wagner grade III or higher; and 
b. Patient has failed an adequate course of standard wound therapy. You can find these rules in National Coverage Determination (NCD) Hyperbaric Oxygen Therapy 20.29. 
 
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 the clinician's rationale for the definitive urine drug testing and the tests ordered must be 
documented in the patient's medical record. You can find this rule in the Local Coverage Determination (LCD) 
- Urine Drug Testing (L36037) - Effective October 1, 2019. 
 
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 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, 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 say that the treatment of individuals with spinal disorders, including pain, can be complex, and it is 
recommended that all individuals being considered for interventional spinal procedures undergo a thorough 
evaluation and be treated following development of a comprehensive care plan. You can find this rule in the 
Local Coverage Determination (LCD) - Epidural Steroid Injections for Pain Management (L39054) - Effective 
October 21, 2021. 
 
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 claims or claim lines that have been determined to be an exact duplicate are rejected and do 
not have appeal rights. An exact duplicate for institutional claims is a claim or claim line that exactly matches 
another claim or claim line with respect to the following elements:  
 
Medicare beneficiary identifier; Type of Bill; Provider Identification Number; From Date of Service; Through 
Date of Service; Total Charges (on the line or on the bill); and Healthcare Common procedure Coding System 
(HCPCS), Current Procedural Terminology (CPT)-4, or Procedure Code modifiers.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 120.2. 
 
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 state that for each covered spinal region, no more than four (4) diagnostic joint sessions will be 
considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator 
cannot always be identified with the initial and confirmatory diagnostic procedure. No more than four (4) 
therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months. You can find this rule 
in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892). 
 
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 only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is 
statutorily non-covered. 
 
You can find this information in the 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.
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 drugs, or drug classes for which testing is performed, should reflect only those likely to be 
present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in 
common use. Drugs for which specimens are being tested must be indicated by the referring provider in a 
written order. 
 
You can find this rule in the Local Coverage Determination (LCD) - Drug Testing (L34645) - Effective 
October 1, 2021. 
 
The rules say that definitive drug testing is indicated when: 
 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. 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 (LCD) - Drug Testing (L34645) - Effective 
October 1, 2021. 
 
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 definitive urine drug testing may be reasonable and necessary based on patient specific 
indications, including historical use, medication response, and clinical assessment, when accurate results are 
necessary to make clinical decisions. The clinicians rationale for the definitive urine drug testing and the tests 
ordered must be documented in the patients medical record. You can find this rule in the Local Coverage 
Determination (LCD) - Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L35724) - 
Effective April 8, 2021. 
 
The rules say that definitive urine drug testing (UDT) is reasonable and necessary for the following 
circumstances: 
 
-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
-Definitively identify specific drugs in a large family of drugs; 
-Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
-Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation 
of THC use according to a treatment plan); 
-Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
-Rule out an error as the cause of a presumptive UDT result; 
-Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
-Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
You can find this rule in the Local Coverage Determination (LCD) - Lab: Controlled Substance Monitoring 
and Drugs of Abuse Testing (L35724) - Effective April 8, 2021. 
 
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 drugs, or drug classes for which testing is performed, should reflect only those likely to be 
present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in 
common use. Drugs for which specimens are being tested must be indicated by the referring provider in a 
written order. You can find this rule in the Local Coverage Determination (LCD) - Drug Testing (L34645) - 
Effective October 1, 2021. 
 
The rules say that definitive drug testing is indicated when: 
 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. 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 (LCD) - Drug Testing (L34645) - Effective 
October 1, 2021. 
 
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 telephone alert systems are noncovered because they are emergency communications 
systems and do not serve a diagnostic or therapeutic purpose. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 280.1. 
 
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 polyethylene-glycol (PEG) hydrogel is covered ONCE in patients with clinically localized 
prostate cancer with BOTH the following: 
 
1. Inclusion criteria, including ALL of the following: 
 
a. Low or Favorable Intermediate Prostate Cancer Risk Group (1-5) (AUA or NCCN criteria 
b. Dose escalated (= 76 Gy) conventional fractionation (1.8-2 Gy fractions) or moderate hypofractionation 
(HFX) (2.4-3.4 Gy fractions) IG-IMRT planned 
c. Eastern Cooperative Oncology Group (ECOG) performance status less than or equal to 1 
d. Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side effects due 
to AT LEAST ONE of the following: 
 
i. Anatomic geometry precluding ideal rectal constraints 
 
-Conventional fractionation (V70 <10%, V65 <20%, V40 <40%) 
-Moderate HPX (dose constraints not yet standardized; employ those used in the supporting phase III trials) 
 
ii. Medication usage (e.g. anticoagulants) 
iii. Comorbid conditions (e.g. increased age, history of myocardial infarction or congestive heart failure) 
 
2. No exclusion criteria, including ALL of the following: 
 
a. Less than 5 year life-expectancy and asymptomatic 
b. Prior prostate cancer treatment (surgery or radiation therapy)  
c. Active bleeding disorder or clinically significant coagulopathy 
d. Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, anorectal 
inflammatory bowel disease) 
e. Prostate volume more than 80 cc 
 
You can find this rule in the Local Coverage Determination (LCD) - Prostate Rectal Spacers (L37485) - 
Effective August 1, 2020. 
 
The rules that a life expectancy of 20 years or more would be considered very low risk, and a life expectancy of 10 years of more would be considered low risk. You can find this rule in the Local Coverage Determination 
(LCD) - Prostate Rectal Spacers (L37485) - Effective August 1, 2020. 
 
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 in order for code 62320 to be covered, certain documentation requirements must be met. 
The documentation must include the legible signature of the physician or non-physician practitioner 
responsible for providing the care to the patient.  In addition, the procedure report should clearly document the 
indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved 
immediately post-injection.  You can find this rule at Wisconsin Physician Service Insurance Corporation 
Local Coverage Article A58777 entitled Billing and Coding: Epidural Steroid Injections for Pain Management. 
 
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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
 
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 non-emergency transportation by ambulance is appropriate if it is documented that the 
members condition is such that other means of transportation could endanger the persons health and that 
transportation by ambulance is medically required. You can find this information on pages 68-69 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 all services billed by a skilled nursing facility (SNF) (including those furnished under 
arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are included in the 
SNF's Part A bill. The SNF must furnish the services either directly or under an arrangement with an outside 
supplier or provider of services in which the SNF (rather than the supplier or provider of services) bills 
Medicare. As a result, the outside supplier must look to the SNF rather than any other party for payment. You 
can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 10.1. 
 
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 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). 
 
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 does not clearly disclose how much enrollees should expect to pay for diabetic shoes and inserts.
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. Some of the services listed in the Medical Benefits Chart are 
covered only if your doctor or other network provider gets approval in advance (sometimes called prior 
authorization) from us. You can find this information on pages 59 to 60 of the Plans 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 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 $275 copayment per one-way trip. You can find this information on 
page 68 of the Plan's 2021 Evidence of Coverage (EOC).