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 state that coverage of neuromuscular electrical stimulation (NMES) to treat muscle atrophy is limited 
to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or 
splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery 
(until orthotic training begins). You can find this information in National Coverage Determination (NCD): 
Neuromuscular Electrical Stimulation (NMES) (160.12). 
 
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 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. 
 
The rules say that computed tomography cerebral perfusion analysis (CTP) is medically reasonable and 
necessary in patients with small acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) 
in the proximal anterior circulation evaluated at stroke centers. CTP can be used to aid in selection for 
endovascular mechanical thrombectomy (EVT) if the enrollee meets the pre-CTP inclusion/exclusion criteria 
as defined by either the Diffusion-weighted imaging or CTP Assessment with Clinical Mismatch in the Triage 
of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo (DAWN) trial, or the 
Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) 3 trial. These 
criteria are listed in the Local Coverage Determination (LCD): Computed Tomography Cerebral Perfusion 
Analysis (CTP) (L38769). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays for medically necessary ambulance transport services. Medicare makes 
separate payment for paramedic intercept services only when they are furnished: 
 
1. in a rural area, 
2. by a provider that is under a contract with 1 or more volunteer ambulance services. You can find this rule at 
42 CFR Section 410.40(d). 
 
The rules say that for the purposes of Paramedic Intercept coverage, an area is a rural area if: 
 It is designated as a rural area by any law or regulation of a State; 
 It is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan 
Area (NECMA); or 
 It is located in a rural census tract of an MSA as determined under the most recent Goldsmith 
modification. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 20.1.4(a)(5). 
 
The rules say that providers must report one of the following HCPCS codes in FL 44 HCPCS/Rates for each 
base rate ambulance trip provided during the billing period: 
A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434. 
These are the same codes required effective for services January 1, 2001. 
 
In addition, providers must report one of HCPCS mileage codes: 
A0425, A0435, or A0436. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 15, Section 30.2.1. 
 
 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 code A9270 represents non-covered items or services.  You can find this rule at Centers for 
Medicare and Medicaid Services, Program Memorandum Carriers, Transmittal B-01-58, Change Request 1820. 
 
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 pages 58 to 59 of the Plan's 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 a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
    The beneficiarys past history (including prior prosthetic use if applicable); and 
 
    The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
 
    The beneficiarys desire to ambulate. 
 
A level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the community 
ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or 
exercise activity that demands prosthetic utilization beyond simple locomotion. 
 
A fluid, pneumatic, or electronic/microprocessor knee (codes L5828,L5848, and L5858) is covered for 
beneficiaries whose functional level is 3 or above. 
 
You can find this information in the Local Coverage Determination (LCD) for Lower Limb Prostheses 
(L33787). 
 
The rules say that L5845 is an additional feature and/or function that does not describe a complete endoskeletal 
knee-shin system and must be used in combination with an L-code for a knee-shin system. You can find this 
information in the Local Coverage Article for Lower Limb Prostheses - Policy Article (A52496). 
 
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 $325 copayment for an in-network diagnostic colonoscopy. You can find 
this information on page 90 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $10 copayment for in-network lab services. You can find 
this information on page 85 of the Plans 2022 EOC. 
 
The Plan contract also says that enrollees must pay 20% coinsurance for in-network Part B drugs. You can find 
this information on page 83 of the Plans 2022 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 the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.   
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. Codes with an MAI of 2 have been rigorously reviewed and vetted within 
CMS and obtain this MAI designation because units of service on the same date of service (DOS) in excess of 
the MUE value would be considered impossible because it was contrary to statute, regulation, or subregulatory 
guidance. 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(V). 
 
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 and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
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. 
 
One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or 
four-level procedure bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., 
medical branch blocks (MBB), Intraarticular (IA), facet cyst ruptures, and radiofrequency ablations (RFAs)) 
that are performed during the same day. You can find this rule in the Local Coverage Determination (LCD): 
Facet Joint Interventions for Pain Management (L34892). 
 
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 
offers additional benefits for certain members at no cost to you. To qualify for these benefits, you just meet 
specific criteria, including having an active diagnosis for one or more qualifying co-morbid and medically 
complex conditions. The condition must be life-threatening or significantly limit the overall health or function 
of the member. Additionally, the member must require intensive care management and be at high risk for 
hospitalization. For a complete list of conditions and detailed eligibility criteria, please visit Chapter 4, Section 
2.1 of the Plan's 2023 Evidence of Coverage (EOC). You can find this information on page 103 of the Plan's 
2023 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 $90 copayment for emergency care. The copayment is waived if you are 
admitted to the hospital as an inpatient. You can find this information on page 77 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 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 pages 58-59 of the Plan's 2023 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 immunizations are not covered unless they are directly related to the treatment of an injury or 
direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation 
is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-
19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of 
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). 
 
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 a status indicator of N represents a non-covered service. You can find this rule in Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
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 a state or local government that has custody of a Medicare beneficiary under a penal statute 
has a financial obligation to pay for the cost of healthcare items and services unless the State can demonstrate 
that State or local law requires that individuals in custody repay the cost of the services and the State or local 
government entity enforces the requirement to pay by billing and seeking collection from all individuals in 
custody with the same legal status, whether insured or uninsured, and by pursuing collection of the amounts 
they owe in the same way and with the same vigor that it pursues the collection of other debts. This includes 
collection of any Medicare deductible and coinsurance amounts and the cost of items and services not covered 
by Medicare.  
 
Providers and suppliers that render services or items to a prisoner or patient in a jurisdiction that meets the 
conditions described above indicate this fact with the use of a modifier or condition code. Otherwise, the claims 
are denied. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 50.3.3. 
 
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.