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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 32-33 in 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 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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 8 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 state that skilled nursing facilities (SNFs) are no longer able to "unbundle" services to an outside 
supplier that can then submit a separate bill directly to an A/B MAC (B) or DME MAC for residents in a Part 
A stay, or for SNF residents receiving physical therapy, occupational therapy, and/or speech-language 
pathology services paid under Part B. Instead, 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. Medicare does not pay amounts that are due a provider to any other person 
under assignment, or power of attorney, or any other direct payment arrangement. As a result, the outside 
supplier must look to the SNF (rather than the A/B MAC (A), or (B), or DME MAC or the beneficiary) for 
payment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
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 that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say home health agencies (HHAs) shall no longer submit Requests for Anticipated Payment (RAPS -
TOB 0322) for any HH period of care with a From date on or after January 1, 2022. Instead, for each admission 
to home health, the HHA notifies Medicare systems via submission of a notice of admission (NOA) An NOA 
must be submitted timely. A timely-filed NOA is submitted to and accepted by the A/B MAC (HHH) within 
five calendar days after admission date. NOAs are submitted using TOB 032A. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 10.1.10.3. 
 
The rules say that all home health agencies (HHAs) must submit an NOA to their Medicare contractor within 5 
calendar days from the start of care date to establish that the beneficiary is under a Medicare home health 
period of care and also to trigger home health consolidated billing edits. In instances where an NOA is not 
timely-filed, Medicare shall reduce the payment for a period of care, including outlier payments, by the number 
of days from the home health admission date until the date the NOA is submitted to, and accepted by, the 
contractor, divided by 30. This reduction shall be a provider liability, and the provider shall not bill the 
beneficiary for it. You can find this information in the Centers for Medicare and Medicaid Services, Internet-
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 10.4. 
 
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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community based 
services. You can find this rule at 42 CFR Section 422.112. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 12 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 all reasonable and necessary diagnostic tests given for specifically listed medical conditions, 
including sleep apnea, are covered when the following criteria are met:  
 
  
  -The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic 
testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision 
by a physician;  
-Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record 
of the attending physicians orders; and  
-The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory 
tests. 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70.  
 
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 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). 
 
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 a repeat polysomnography (PSG) or home sleep test (HST) for diagnosing sleep apnea 
requires documentation justifying the medical necessity for the repeated test. Repeat PSG may be indicated: 
 
 if the first study is technically inadequate due to equipment failure; 
 if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; 
 if the results were inconclusive or ambiguous; or 
 if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed. 
 
You can find this information in the Local Coverage Determination (LCD) for 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 state that three-dimensional imaging is medically reasonable and necessary only if the outcome will 
potentially impact the diagnosis or clinical course of the patient. Providers are encouraged to obtain additional 
information from referring providers and/or patients or medical records to determine the medical necessity of 
studies performed. Referring physicians are required to provide appropriate diagnostic information to the 
performing provider. 
 
As with any diagnostic testing, the procedure should be furnished in accordance with accepted standards of 
medical practice based on the patients diagnosis, signs, and symptoms. This additional procedure applied to a 
base procedure must meet but not exceed the patients medical need. 
 
Three dimensional rendering codes should be reserved for situations where the additional image is necessary 
for a complete depiction of an abnormality from the 2D study or for surgical planning. 
 
For non-hospital based outpatient services, it is expected that the ordering/referring physician/non-physician 
practitioner generate a written order/referral indicating the medical necessity for the additional 3D imaging. In 
addition, it is expected that the interpreting physician maintain a copy of the test results and interpretation 
along with a copy of the ordering/referring physician/non-physician practitioners order for the study. The 
interpreting physicians report should address the medical necessity identified by the ordering/referring 
physician/non-physician practitioner. In the event it is deemed by the interpreting physician that a 3D 
interpretation is urgently needed and the ordering/referring physician/non-physician practitioner is not 
immediately available, the interpreting physician must document the following on the radiology report: the 
time of the study; specific medical need for the study; and a legible summary of the findings that were urgently 
transmitted to the ordering/referring physician/non-physician practitioner whose name is on the order for the 
study. 
 
For hospital based services (inpatient/outpatient), it is expected that there should be an order for the 3D image. 
In the absence of the order for the 3D image, if the hospitals interpreting physician deems that the 3D 
interpretation is needed, he or she should clearly state in the interpretation the medical necessity for this 
separate service, in addition to the base procedure.  
You can find this information in the Local Coverage Determination (LCD) 3D Interpretation and Reporting of 
Imaging Studies L33256. 
 
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 state that the patient must have for Percutaneous Left Atrial Appendage Closure (LAAC) coverage: 
 
    A CHADS2 score = 2 (Congestive heart failure, Hypertension, Age > 75, Diabetes, Stroke/transient ischemia 
attack/thromboembolism) or CHA2DS2-VASc score = 3 (Congestive heart failure, Hypertension, Age = 65, 
Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular disease, Sex category) 
    A formal shared decision making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the 
shared decision making interaction must be documented in the medical record. 
    A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the 
conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. 
The patient (preoperatively and postoperatively) is under the care of a cohesive, multidisciplinary team (MDT) 
of medical professionals. The procedure must be furnished in a hospital with an established structural heart 
disease (SHD) and/or electrophysiology (EP) program. 
 
You can find this information in the National Coverage Determination (NCD) Percutaneous Left Atrial 
Appendage Closure (LAAC) 20.34. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 32 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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each 
provider and supplier enroll with the appropriate Medicare fee-for-service contractor. You can find this rule in 
the Medicare Program Integrity Manual, Chapter 15, Section 15.1. 
 
The rules say that pursuant to the Social Security Act, Medicare does not recognize substance abuse treatment 
facilities as an independent provider type, nor is there an integrated payment for the bundle of services those 
providers may provide (either directly, or incident to a physicians service). You can find this rule in the 
Department of Health and Human Services, Centers for Medicare & Medicaid Services, MLN Matters Number 
SE1604, April 28, 2016 - Medicare Coverage of Substance Abuse Services. 
 
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 for either a clinical laboratory test or the technical component of physician pathology service 
the date of service (DOS) of the test/service must be the date the specimen was collected. If a specimen is 
collected over a period that spans two calendar days, then the DOS must be the date the collection ended. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
04, Medicare Claims Processing Manual Chapter 16, Section 40.8. 
 
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. While the Plan offers a Point-of-Service option for coverage of 
out-of-network services, this benefit only applies to dental services. You can find this information on pages 27 
to 28 of the Plan's 2023 Evidence of Coverage (EOC).