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 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 state that Medicare Part B coverage is available for outpatient Opioid Treatment Program services 
provided by hospitals, CAHs, and Free-Standing Opioid Treatment Program facilities. You can find this rule at 
the Medicare Claims Processing Manual, Chapter 39, section 50- Institutional Opioid Treatment Program 
(OTP) Services  A/B MAC (A). 
 
The rules state that beginning January 1, 2020, claims for OTP services are submitted using the 837P 
transaction to transmit health care claims electronically, or using the CMS-1500 (the paper version of the 
837P). Beginning January 1, 2021, OTPs may apply on the Medicare Enrollment Application for Institutional 
Providers (CMS-855A) or through the Internet-based Provider Enrollment, Chain and Ownership System 
(PECOS) (837I) when they enroll in the Medicare Program. These providers will submit claims using the 
CMS-1450. You can find this rule at the Medicare Claims Processing Manual, Chapter 39, section 40- 
Practitioner Claims submission  A/B MAC (B). 
 
The rules state that OTPs should list the prescribing or medication ordering physicians or other eligible 
professionals National Provider Identifier in Field 17 (the ordering/referring/other field) of the Form CMS
1500 (Health Insurance Claim Form; 09381197) or the digital equivalent thereof. You can find this rule at the 
Medicare Claims Processing Manual, Chapter 39, section 40.3 - Prescribing Individuals. 
 
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 page 174 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 use of water vapor thermal therapy for the treatment of lower urinary tract symptoms attributable to benign 
prostatic hyperplasia (LUTS/BPH) may be covered in the following circumstances. 
 
ONE treatment for LUTS/BPH treatment is covered ONCE in patients with BOTH the following:  
 
    Indications including ALL of the following: 
 
        Age greater than or equal to 50 
 
        Symptomatic despite maximal medical management including ALL of the following: 
 
            International Prostate Symptom Score (IPSS) greater than or equal to 13 
 
            Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 
cc) 
 
            Failure, contraindication or intolerance to at least three months of conventional medical therapy for 
Benign prostatic hyperplasia (BPH) (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
        Prostate volume of 30-80 cc, 
 
        Poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, 
pulmonary disease, etc.), or at high risk of bleeding 
 
    No contraindications including ALL of the following: 
 
        Known or suspected prostate cancer (based on National Comprehensive Cancer Network (NCCN) 
Prostate Cancer Early Detection guidelines) or a prostate specific antigen (PSA) greater than 10 ng/mL 
 
        Active urinary tract infection 
 
        History of bacterial prostatitis in the past three months 
 
        Prior prostate surgery  
        Neurogenic bladder 
 
        Active urethral stricture (i.e., the source of the current LUTS) 
 
You can find this information in the Local Coverage Determination (LCD):(L37808) Water Vapor Thermal 
Therapy for LUTS/BPH. 
 
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 supplier-produced records, even if signed by the treating practitioner, and attestation letters 
(e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment 
purposes. Templates and forms, including CMS CMNs, are subject to corroboration with information in the 
medical record. A prescription is not considered to be part of the medical record. Medical information intended 
to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated 
by information contained in the medical record. The beneficiarys medical record must contain sufficient 
documentation of the beneficiarys medical condition to substantiate the necessity for the type and quantity of 
items ordered and for the frequency of use or replacement (if applicable). The information should include the 
beneficiarys diagnosis and other pertinent information including, but not limited to, duration of the 
beneficiarys condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. You can find this 
information in Medicare's Local Coverage Article: Standard Documentation Requirements for All Claims 
Submitted to DME MACs (A55426). 
 
The rules say that the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) must have an order from the treating physician before giving any DMEPOS item to an enrollee. 
The supplier must keep the order and proof of delivery documentation on file. All services that do not have 
appropriate proof of delivery will be denied. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 
5.2.1 and 5.8. 
 
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 Institutional providers may submit a taxonomy code on claims they submit to Medicare. 
Medicare does not use the taxonomy code for matching a providers NPI to the appropriate legacy identifier. 
Medicare uses other claims data for this purpose. Medicare does not use the taxonomy code for any other 
claims processing purpose. Payers other than Medicare may have requirements for taxonomy codes. Medicare 
will pass any taxonomy code submitted on a Medicare claim to our trading partners on crossover claims, to 
allow for the possibility that those payers may use it. You can find this rule in the Centers for Medicare & 
Medicaid Services, Medicare Claims Processing Manual, Chapter 1, Section 160.1. 
 
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 state that Medicare Part B coverage is available for outpatient Opioid Treatment Program services 
provided by hospitals, CAHs, and Free-Standing Opioid Treatment Program facilities. You can find this rule at 
the Medicare Claims Processing Manual, Chapter 39, section 50- Institutional Opioid Treatment Program 
(OTP) Services  A/B MAC (A). 
 
The rules state that beginning January 1, 2020, claims for OTP services are submitted using the 837P 
transaction to transmit health care claims electronically, or using the CMS-1500 (the paper version of the 
837P). Beginning January 1, 2021, OTPs may apply on the Medicare Enrollment Application for Institutional 
Providers (CMS-855A) or through the Internet-based Provider Enrollment, Chain and Ownership System 
(PECOS) (837I) when they enroll in the Medicare Program. These providers will submit claims using the 
CMS-1450. You can find this rule at the Medicare Claims Processing Manual, Chapter 39, section 40- 
Practitioner Claims submission  A/B MAC (B). 
 
The rules state that OTPs should list the prescribing or medication ordering physicians or other eligible 
professionals National Provider Identifier in Field 17 (the ordering/referring/other field) of the Form CMS
1500 (Health Insurance Claim Form; 09381197) or the digital equivalent thereof. You can find this rule at the 
Medicare Claims Processing Manual, Chapter 39, section 40.3 - Prescribing Individuals. 
 
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 not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 covers certain dental services as a supplemental (extra) benefit. You can find this information 
on pages 63-67 of the Plans 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 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 20% coinsurance for in-network Medicare Part B covered drugs. You 
can find this information on pages 73-74 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $40 copayment for in-network lab services provided at an 
outpatient hospital facility. 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 specific information on end-stage renal disease (ERSD) claims must be submitted in order 
for the claim to be processed. You can find this rule in the Centers for Medicare and Medicaid Services, 
Medicare Claims Processing Manual, Chapter 8, Section 10. 
 
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 series* of hyaluronan knee injection(s) for patients who have responded to a prior 
series is considered to be reasonable and necessary under the following circumstances: 
 Symptoms have recurred 
And, 
 At least six months have elapsed since the prior series of injections 
And, 
 There was significant improvement in pain and functional capacity achieved with the prior series of 
injections using a standardized assessment tool 
Or, 
 There is significant reduction in the doses of NSAID medications taken or reduction in the number of 
intra-articular steroid injections to the knees during the six-month period following the injection(s). 
*Note: A series is defined as a set of injections for each joint and each treatment (initial or repeat). You can 
find this rule at Local Coverage Determination (LCD) L35427: Hyaluronan Acid Therapies for Osteoarthritis 
of the Knee (eff. 10/1/19). 
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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. 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 27 to 31 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 multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. You can 
find this information in the Centers for Medicare and Medicaid Services, Local Coverage Determination: 
MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels (L37713). 
 
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 P identifies a bundled code. There are no relative 
value units (RVUs) and no payment amounts for these services. No separate payment is made for them under 
the fee schedule. If the item or service is covered as incident to a physician service and is provided on the same 
day as a physician service, payment for it is bundled into the payment for the physician service to which it is 
incident (an example is an elastic bandage furnished by a physician incident to a physician service). If the item 
or service is covered as other than incident to a physician service, it is excluded from the fee schedule (for 
example, colostomy supplies) and is paid under the other payment provision of the Act. 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 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 P means that these codes are bundles/excluded. 
There are no relative value units (RVUs) and no payment amounts for these services. No separate payment is 
made for them under the fee schedule. 
 
If the item or service is covered as incident to a physician service and is provided on the same day as a 
physician service, payment for it is bundled into the payment for the physician service to which it is incident 
(an example is an elastic bandage furnished by a physician incident to a physician service). 
 
If the item or service is covered as other than incident to a physician service, it is excluded from the fee 
schedule (for example, colostomy supplies) and is paid under the other payment provision of the Act.   
 
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.