Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Food & Drug Administration (FDA)-approved hypoglossal nerve neurostimulation (HGNS) 
is considered medically reasonable and necessary for the treatment of moderate to severe obstructive sleep 
apnea when all of the following criteria are met: 
1. Beneficiary is 22 years of age or older; and 
2. Body mass index (BMI) is less than 35; and 
3. A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and 
4. Beneficiary has predominantly obstructive events; and 
5. Apnea-hypopnea index (AHI) is 15 to 65 events per hour; and 
6. Beneficiary has documentation that demonstrates continuous positive airway pressure (CPAP) failure 
(defined as AHI greater than 15 despite CPAP usage) or CPAP intolerance (defined as less than 4 hours 
per night, 5 nights per week or the CPAP has been returned) including shared decision making that the 
patient was intolerant of CPAP despite consultation with a sleep expert: and 
7. Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep 
endoscopy (DISE) procedure; and 
8. No other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per 
standardized tonsillar hypertrophy grading scale). 
 
You can find these rules in Local Coverage Determination (LCD) Hypoglossal Nerve Stimulation for the 
Treatment of Obstructive Sleep Apnea (L38307). 
 
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 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. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
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. The Plan 
contract also says while you can get your care from an out-of-network provider, the provider must be eligible to 
participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate 
in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible 
for the full cost of the services you receive. Check with your provider before receiving services to confirm that 
they are eligible to participate in Medicare. You can find this information on page 45 of the Plans 2022 
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 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 X means that these codes represent an item or 
service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No 
payment amounts are shown for these codes, and no payment may be made under the physician fee schedule. 
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 starting in calendar year 2023, hospital inpatient and observation care by practitioners will be 
billed using the same CPT codes, CPT codes 99221 through 99223, 99231 through 99233, and 99238 and 
99239. Although observation care codes (CPT codes 99218 through 99220 and 99224 through 99226) are 
being deleted, practitioners will still be able to furnish and bill for observation services using the revised 
Hospital Inpatient or Observation Care Services code set. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 12, Section 30.6.8(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.
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 99 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 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 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, Section 3.3.2.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that reasonably complete information must be adequately documented in the patients medical 
records to demonstrate the reasonableness and necessity of the procedure(s) performed. In general and where 
applicable, clinical notes, and physical findings rather than formal visual field testing, should support a 
decrease in the superior field of vision and/or peripheral vision. While they may be performed to demonstrate 
to the patient (if needed) the potential for improvement, or if required by the prevailing standard of care, this 
policy does not consider the visual field testing in documenting a procedure as reasonable and necessary. 
Exceptions may be considered on appeal. You can find this rule in the Local Coverage Determination (LCD) - 
Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) - Effective October 1, 2019. 
 
The rules say that photographs are required to support upper eyelid surgery as reasonable and necessary. The 
physical signs documented must be clearly represented in photographs of the structures of interest and the 
photographs must be of good quality and of sufficient size and detail as to make those structures easily 
recognizable. The patients head and the camera must be in parallel planes, not tilted so as not to distort the 
appearance of any relevant finding (e.g., a downward head tilt might artificially reduce the apparent 
measurement of a MRD). For blepharoptosis repair: 
 
1. Photographs of both eyelids in the frontal (straight-ahead) position should demonstrate the MRD. If the 
eyelid obstructs the pupil, there is a clear-cut indication for surgery. (For reference, the colored part of the eye 
is about 11 mm in diameter, so the distance between the light reflex and the lid would need to be about one 
fifth that distance or less for the MRD to be 2.0 mm or less.) 
2. In the special case of documenting the need for bilateral surgery because of Herrings law, two photos are 
needed:One showing both eyes of the patient at rest demonstrating the above MRD criterion in the more ptotic 
eye, and another showing both eyes of the patient with the more ptotic eyelid raised to a height restoring a 
normal visual field, resulting in increased ptosis (meeting the above MRD standard) in the less ptotic eye. 
 
You can find this rule in the Local Coverage Determination (LCD) - Blepharoplasty, Eyelid Surgery, and Brow 
Lift (L36286) - Effective October 1, 2019. 
 
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. 
 
Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to 
each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 
090, and, sometimes, YYY. Codes with 090 in Field 16 are major surgeries.  
 
The rules say that modifier 79 reports an unrelated procedure by the same physician during a postoperative 
period. The physician may need to indicate that the performance of a procedure or service during a 
postoperative period was unrelated to the original procedure. A new postoperative period begins when the 
unrelated procedure is billed. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40. 
 
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 that physicians and suppliers must use healthcare common procedure coding system (HCPCS) 
codes on the Form CMS-1500 or its electronic equivalent and providers must use HCPCS codes on the Form 
CMS-1450 or its electronic equivalent for most outpatient services. The procedure, item, or service can be 
further described by using 2-position modifiers contained in HCPCS. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 20.3. 
 
The rules say that when coding HCPCS for outpatient services, the provider enters the HCPCS code describing 
the procedure. The HIPPS rate code consists of the three-character resource utilization group (RUG) code that 
is obtained from the "Grouper" software program followed by a 2-digit assessment indicator (AI) that specifies 
the type of assessment associated with the RUG code obtained from the Grouper. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 25, Section 25.5. 
 
The rules say that to report home health visits, the home health agency reports a G-code to represent a visit by 
each home health care discipline. The location where services were provided must always be reported along 
with the first visit reported on the claim. In addition to reporting a visit line using the G codes, HHAs must 
report an additional line item with the same revenue code and date of service, reporting one of the three Q 
codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny). 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 40.2. 
 
 
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 the enrollee must have at least 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. You can find these rules in 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 coverage for neuromuscular electrical stimulation (NMES)/functional electrical stimulation 
(FES) for walking will be covered in spinal cord injury (SCI) patients with all of the following characteristics: 
1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); 
2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can 
demonstrate balance and control to maintain an upright support posture independently; 
3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical 
stimulation sufficient for muscle contraction; 
4. Persons that possess high motivation, commitment and cognitive ability to use such devices for 
walking; 
5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 
3 minutes; 
6. Persons that can demonstrate hand and finger function to manipulate controls; 
7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery; 
8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to 
osteoporosis; and 
9. Persons who have demonstrated a willingness to use the device long-term. 
 
NMES/FES for walking will not be covered in SCI patient with any of the following: 
1. Persons with cardiac pacemakers; 
2. Severe scoliosis or severe osteoporosis; 
3. Skin disease or cancer at area of stimulation; 
4. Irreversible contracture; or 
5. Autonomic dysflexia. 
 
You can find these rules in National Coverage Determination (NMES) Neuromuscular Electrical Stimulation 
(160.12). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 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: 
 
1. Initial thermal RFA: After the patient has had at least two (2) medically reasonable and necessary diagnostic 
medial branch blocks, 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 
 
2. 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 as compared to baseline measurement using the same scale. 
 
You can find this rule 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.