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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare & Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
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 knee orthosis with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), is covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s). Knee instability must be documented by examination of the 
beneficiary and objective description of joint laxity. This rule is found in Medicare Local Coverage 
Determination (LCD): Knee Orthoses (L33318). 
 
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 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 pages 38-47 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 for a Group 3 Single Power Option power wheelchair to be covered, there must be medical 
need for a special drive control (including, but not limited to, head control, sip and puff, switch control) or for a 
single power option: either power tilt or power recline. This rule is found in Local Coverage Determination 
(LCD) Power Mobility Devices (L33789). 
 
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 case-mix methodology adjusts the 30-day payment rate based on characteristics of the 
patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other 
factors). The 30-day period payment rate is adjusted by a case-mix methodology based on information from 
home health claims, other Medicare claims, and data elements from the OASIS. The claims information and 
OASIS data elements are used to group 30-day periods of care into their case-mix groups. You can find this 
rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-02, Medicare 
Benefit Policy Manual, Chapter 7, Section 10.2. 
 
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 to qualify for home health services, the patient must be: 
 
  
  1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare & Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
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 interpret the phrase new patient to mean a patient who has not received any professional 
services, i.e., evaluation and management (E/M) service or other face-to-face service (e.g., surgical procedure) 
from the physician or physician group practice (same physician specialty) within the previous 3 years. For 
example, if a professional component of a previous procedure is billed in a 3-year time period, e.g., a lab 
interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this 
patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or 
electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient 
does not affect the designation of a new patient. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 12, Section 
30.6.7. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say to group diagnoses into the proper diagnosis related group (DRG), CMS needs to identify a 
Present on Admission (POA) Indicator for all diagnoses reported on claims involving inpatient admissions to 
general acute care hospitals.  Use the UB-04 Data Specifications Manual and the Official International 
Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and 
Reporting to facilitate the assignment of the POA indicator for each "principal" diagnosis and "other" 
diagnoses codes reported on claim forms UB-04 and 837 Institutional.   
 
The POA Indicator guidelines are not intended to provide guidance on when a condition should be coded, 
rather to provide guidance on how to apply the POA Indicator to the final set of diagnosis codes that have been 
assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the 
assignment of the ICD-10-CM codes, the POA Indicator should be assigned to all diagnoses that have been 
coded. 
 
You can find this rule in the Centers for Medicare & Medicaid Services Coding for Hospital-Acquired 
Conditions.  
 
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 pay for acute inpatient hospital services when: 
 
1. The patients signs and symptoms and general medical condition can only be managed safely in an 
acute inpatient setting,  
2. The enrollee requires diagnostic studies in an inpatient setting, or 
3. It is medically necessary for the enrollee to remain in the acute inpatient setting.  
 
The doctor responsible for a patient's care is responsible for deciding whether the patient should be admitted as 
an inpatient. Doctors should use a 24-hour period as a benchmark. This means they should order admission for 
patients who are expected to need hospital care for 24 hours or more and treat other patients on an outpatient 
basis. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 10. 
 
The rules define observation services as outpatient services which include ongoing short-term treatment, 
assessment, and reassessment. During observation, the doctor will decide whether to discharge a patient from 
the hospital or admit the patient as an inpatient. You can find these rules in the Centers for Medicare & 
Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, 
Section 20.6. 
 
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 custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive 
sleep apnea (OSA) is covered if criteria A - D are met. 
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-
related Policy Article for applicable diagnoses. 
B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3):  
1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or 
equal to 15 events per hour with a minimum of 30 events; or, 
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a 
minimum of 10 events and documentation of:  
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
b. Hypertension, ischemic heart disease, or history of stroke; or, 
3. If the AHI> 30 or the RDI> 30 and meets either of the following(a or b):  
a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
b. The treating practitioner determines that the use of a PAP device is contraindicated. 
C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who 
performed the clinical evaluation in criterion A.) 
D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. You can find these rules in Local Coverage Determination (LCD) Oral Appliances 
for Obstructive Sleep Apnea L33611. 
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 an electrical bone growth stimulator is covered only for the following indications: 
 
1. Nonunion of long bone fractures;  
 
2. Failed fusion, where a minimum of 9 months has elapsed since the last surgery;  
 
3. Congenital pseudarthroses;  
 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 150.2. 
 
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). 
 
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 $5 copayment for in-network physician/practitioner services, including 
doctors office visits.  You can find this information on page(s) 79 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 quantity of test strips (code A4253) and lancets (code A4259) that are covered depends on the usual 
medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of 
their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. Coverage of testing supplies is 
based on the following guidelines: 
 
Usual Utilization 
 
For a beneficiary who is not currently being treated with insulin administrations, up to 100 test strips and up to 
100 lancets every 3 months are covered if the basic coverage criteria (1)-(2) (above) are met. 
 
For a beneficiary who is currently being treated with insulin administrations, up to 300 test strips and up to 300 
lancets every 3 months are covered if basic coverage criteria (1)-(2) (above) are met. 
 
High Utilization 
 
For a beneficiary who is not currently being treated with insulin administrations, more than 100 test strips and 
more than 100 lancets every 3 months are covered if criteria (a)(c) below are met. 
 
For a beneficiary who is currently being treated with insulin administrations, more than 300 test strips and 
more than 300 lancets every 3 months are covered if criteria (a)(c) below are met. 
 
Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and supplies 
are met; and, 
 
Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, 
the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and 
their need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and, 
 
Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen. 
 
If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and 
necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria 
(a)(c) are not met, the amount in excess will be denied as not reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Glucose Monitors 
(L33822). 
 
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 the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
1. stress fracture. 
2. spondylosis. 
3. infection (e.g., discitis). 
4. tumor (e.g., osteoid osteoma). 
5. analyze blood flow to an organ, as in the case of myocardial viability. 
6. differentiate ischemic heart disease from dilated cardiomyopathy. 
 
You can find this information in the Centers for Medicare & Medicaid Services, Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 220.12. 
 
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 state that coverage for codes 64400, 64405, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 
64430, 64445, 64446, 64447, 64448, 64449, 64454 and 64624 is limited to only certain diagnosis codes. You 
can find this rule in the Local Coverage Article (LCA) for Billing and Coding: Peripheral Nerve Blocks 
(A57452). 
 
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 your out-of-network (POS) deductible is $1,500 which applies to certain items and 
services. The Plan deductible applies to the chiropractic services. You can find this information on pages 51-52 
and 65 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 a user-adjustable heel-height feature (L5990) will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
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.