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 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 items and services furnished outside the United States are excluded from coverage except for 
the following services, and certain services rendered on board a ship: 
- Emergency inpatient hospital services where the emergency occurred: 
~ While the beneficiary was physically present in the United States; or 
~ In Canada while the beneficiary was traveling without reasonable delay and by the most direct 
route between Alaska and another State. 
- Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the 
United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's 
United States residence than the nearest participating United States hospital which was adequately 
equipped to deal with and available to provide treatment of the illness or injury; 
- Physician and ambulance services furnished in connection with a covered foreign hospitalization. 
Program payment may not be made for any other Part B medical and other health services, including 
outpatient services furnished outside the United States; 
- Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, 
or departed from, a United States port, are considered to have been furnished in United States territorial 
waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or 
departed from, a United States port, are considered to have been furnished outside United States 
territorial waters, even if the ship is of United States registry; and 
- The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto 
Rico, the Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of 
services rendered on a ship, includes the territorial waters adjoining the land areas of the United States. 
 
You can find these rules in Medicare Benefit Policy Manual Chapter 16, Section 60. 
 
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 follow-up polysomnography (PSG) or home sleep study (HST) is not routinely indicated for 
patients treated with continuous positive airway pressure (CPAP), whose symptoms continue to be resolved 
with CPAP treatment. Follow-up PSG may be indicated; however, under the following circumstances: 
 
 After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing 
disorders to ascertain whether CPAP is still needed at the previously titrated pressure; 
 After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are 
again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; 
or 
 When clinical response is insufficient or when symptoms return despite a good initial response to treatment 
with CPAP. 
 
You can find this information in the Local Coverage Determination (LCD): Polysomnography (L36593). 
 
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 air ambulance services only if the enrollees medical condition is such that 
transportation by either basic, the provision of medically necessary supplies and services or advanced life 
support, an emergency medical technician (EMT) intermediate or EMT-Paramedic ground ambulance is not 
appropriate. Air ambulance services may be covered only if: 
 
1. certain vehicle and crew requirements are met; 
 
2. the enrollees medical condition needed immediate and rapid ambulance transport that could not have been 
provided by ground ambulance; and  
 
3. either the point of pickup is not accessible by ground vehicle or great distances or other obstacles are 
involved in getting the patient to the nearest hospital with appropriate facilities. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 10, Sections 10.4, and 10.4.1, and 30.1.1. 
 
The rules say that claims processing instructions At A/B Medicare Administrative Contractor (MAC) and 
durable medical equipment (DME) MAC discretion, claims submitted using the GY modifier may be auto-
denied. If the GZ and GA modifiers are submitted for the same item or service, treat the item or service as 
having an invalid modifier and therefore unprocessable. Effective for dates of service on and after July 1, 2011, 
A/B MACs shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs shall not 
perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make 
all language published in educational outreach materials, articles, and on their Web sites, consistent to state all 
claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. You can find this information in the Medicare Claims Processing Manual, Chapter 23 
- Fee Schedule Administration and Coding Requirements, C20.9.1.1 - Instructions for Codes With Modifiers 
(A/B MACs (B) Only). 
 
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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet all the 
following criteria: 
a. Initial thermal radiofrequency ablation (RFA): 
i. After the patient has had at least two (2) medically reasonable and necessary diagnostic medial 
branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief 
of primary (index) pain (with the duration of relief being consistent with the agent used) and 
ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable 
and necessary provided the patient had a minimum of consistent 50% improvement in pain for at 
least six (6) months or at least 50% consistent improvement in the ability to perform previously 
painful movements and activities of daily living (ADLs) as compared to baseline measurement 
using the same scale 
 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38803). 
 
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 facet joint interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
 
1. Moderate-to-severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to non-invasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38765). 
 
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 parenteral nutrition to be considered reasonable and necessary, the treating practitioner 
must document that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that 
enteral nutrition (EN) exacerbates gastrointestinal tract dysfunction. The beneficiary must have (a) a condition 
involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients 
or (b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to 
be transported through and absorbed by the gastrointestinal (GI) system. The beneficiary must have a 
permanent impairment. You can find this information in Local Coverage Determination (LCD): Parenteral 
Nutrition (L38953). 
 
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 multi-positional patient transfer system (E0636, E1035, E1036) is covered if both of the 
following criteria 1 and 2 are met:   
 
1. The basic coverage criteria for a lift are met; and 
2. The beneficiary requires supine positioning for transfers 
 
If either criterion 1 or 2 is not met, codes E0636, E1035, and E1036 will be denied as not reasonable and 
necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Patient Lifts (L33799). 
 
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 code A4224 is all-inclusive and describes all necessary supplies (excluding the insulin 
reservoir  see code A4225) used with an external infusion pump (E0784) for the administration of continuous 
subcutaneous insulin and includes, but is not limited to, all cannulas, needles, dressings and infusion supplies. 
Separate billing for any item including an item using a specific HCPCS code, if one exists, will be denied as 
unbundling. You can find this rule in Local Coverage Article External Infusion Pumps - Policy Article 
A52507. 
 
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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet all the 
following criteria: 
 
a. Initial thermal radio frequency ablation (RFA): 
i. After the patient has had at least two (2) medically reasonable and necessary diagnostic medial 
branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief 
of primary (index) pain (with the duration of relief being consistent with the agent used) and 
ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable 
and necessary provided the patient had a minimum of consistent 50% improvement in pain for at 
least six (6) months or at least 50% consistent improvement in the ability to perform previously 
painful movements and activities of daily living (ADLs) as compared to baseline measurement 
using the same scale. 
 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L35936). 
 
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 consider Total Knee Arthroplasty (TKA) medically reasonable and necessary 
when three or more of the following criteria are met: 
 
1. Advanced joint disease demonstrated by radiographic supported evidence or magnetic resonance 
imaging (MRI), e.g., fracture or deterioration, distortion of joint surfaces, subchondral cysts, subchondral 
sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis; 
2. History of unsuccessful appropriate conservative therapy that is clearly documented in the pre-
procedure medical record. Non-surgical medical management is usually implemented for 3 months or more to 
assess effectiveness. Conservative treatment as clinically appropriate for the patients current episode of care 
typically includes one or more of the following: anti-inflammatory medications; analgesics; flexibility and 
muscle strengthening exercises with supervised physical therapy. 
3. Pain with functional disability due to arthritis or trauma to the knee joint; activities of daily living 
(ADLs) are diminished despite compliance with plan of care including activity restrictions as is reasonable, 
assistive device use, weight reduction as appropriate or therapeutic injections into the knee as appropriate; 
4. Distinct structural abnormalities such as: 
   - Distal femur fracture; 
   - Proximal tibia fracture; 
   - Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; 
   - Avascular or other form of osteonecrosis of the knee; 
   - Rheumatologic changes precluding or inconsistent with rehabilitation 
5. Failed previous joint replacement/arthroplasty necessitating revision as indicated by any of the 
following: 
   - Loosening, fracture, or mechanical failure of one or more components; 
   - Technical or functional failure of previous knee surgery, e.g. unicompartmental knee replacement; 
   - Previous osteotomy or partial arthroplasty; 
   - Infection; 
   - Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella; Implant or knee 
malalignment; 
   - Bearing surface wear leading to symptomatic synovitis;    - Tibiofemoral or extensor mechanism instability; or 
   - Knee stiffness, arthrofibrosis or other destructive conditions that render the knee impaired to the extent 
to preclude employment or functional activities. 
 
You can find this information in the Local Coverage Determination (LCD): Lower Extremity Major Joint 
Replacement (Hip and Knee) (L36007). 
 
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 the Physician Fee Schedule Status Indicator N means that this this is a non-covered service. 
These services are not covered by Medicare. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
23, 30.2.2. 
 
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 an intrapulmonary percussive ventilator (IPV) (E0481) has not been demonstrated to be 
reasonable and necessary in the home setting. It will be denied as not medically necessary. You can find this 
rule in the Local Coverage Determination (LCD) Intrapulmonary Percussive Ventilation System L33786. 
 
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 revenue code 0270 is considered a packaged service for Part B inpatient services. You can 
find this rule in the Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing 
Manual, Chapter 4, Section 240.2. 
 
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 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 also says that there is $250 combined deductible which applies to certain items and services. The Plan 
deductible applies to the surgical pathology services. You can find this information on page 44 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 state that effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
   a. Patient has: 
 
    either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
    not been previously tested with the same test using NGS for the same cancer genetic content, and 
    decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
   b. The diagnostic laboratory test using NGS must have: 
 
    Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
    an FDA-approved or -cleared indication for use in that patients cancer; and, 
    results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this information National Coverage Determination (NCD) Next Generation Sequencing (NGS) 
90.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.