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 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 a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following 
indications:  
1. To reduce pain by restricting mobility of the trunk; or  
2. To facilitate healing following an injury to the spine or related soft tissues; or  
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or  
4. To otherwise support weak spinal muscles and/or a deformed spine.  
 
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically 
necessary. You can find this rule at Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO 
(L33790). 
 
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 routine use of Immune Globulins for treatment of Myasthnia gravis (MG) is not indicated. 
Intravenous Immunoglobulin (IVIG) may be considered in patients with severe MG to treat acute severe 
decompensation when other treatments have been unsuccessful or are contraindicated. You can find this 
information in the Local Coverage Determination (LCD): Immune Globulin (L34771). 
 
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 WCE is indicated for coverage under the following circumstances: 
 
    1. WCE is indicated for the diagnosis of occult gastrointestinal bleeding (i.e., likely involving the small 
intestine), the site of which has not previously been identified by any of the following: upper gastrointestinal 
endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. 
    2. WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy and these 
tests have failed to reveal a source of bleeding. Medicare would not expect to see a WCE provided if upper and 
lower endoscopy has not previously been performed. Documentation in the medical record must indicate that 
the beneficiary has suspected GI blood loss with or without anemia. Appropriate differential diagnoses for the 
evaluation of such bleeding include: 
        Angiodysplasia 
        Neoplasm 
        Iron deficiency anemia, which is unexplained after upper and lower endoscopy 
        Zollinger-Ellison syndrome 
        Tuberculosis 
        Vasculitis 
        Radiation enteritis 
        Meckels diverticulum 
        Jejunal diverticula 
        Chronic mesenteric ischemia 
    3. Other indications include the management of celiac disease (e.g., surveillance for small-intestinal cancer) 
and of Crohns disease (that is, either Crohns disease is suspected, but not diagnosed, or colonic involvement 
of Crohns disease is known, but it is necessary to determine whether there is also involvement of the small 
bowel). In addition, WCE is indicated where an indeterminate type of colitis exists, but where a more specific 
diagnosis is being sought via small bowel evaluation. 
    4. Esophageal capsule endoscopy may be used in the evaluation of esophageal varices in patients with portal 
hypertension, as an alternative to upper GI endoscopy. 
 
You can find this information in the Local Coverage Determination (LCD) for Wireless Capsule Endoscopy 
(L35089). 
 
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 Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 
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 20.9. 
 
The rules say that Physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. You can find this rule in Medicare Claims 
Processing Manual, Chapter 12, Section 30.6.5. 
 
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 stent may be placed as a planned adjunct to angioplasty rather than in response to a 
suboptimal or failed angioplasty. Primary endovenous stenting is justified for situations where angioplasty 
alone is not expected to provide a durable result. Endovenous stents may be placed for patients with severely 
symptomatic venous obstructions due to any of the following: 
1. Iliac vein compression syndrome also known as May-Thurner or Cockett syndrome. 
2. Iliocaval obstruction. 
3. Iliofemoral obstruction for patients with venous leg ulceration(s) not relieved by conservative therapies 
and compression. Progression of symptoms may lead to Phlegmasia Cerulea Dolens (PCD), acute 
inferior vena cava (IVC) thrombosis, and rapid thrombus extension despite anticoagulation as well as 
anatomically extensive DVT affecting the common femoral and/or iliac vein, or post-thrombotic 
stenosis with ankle edema of venous origin. 
4. Superior or Inferior Vena Caval Thrombosis including Superior Vena Cava syndrome. 
5. Post-thrombotic syndrome (PTS). 
6. As an adjunct to catheter-directed thrombolysis for acute femoroiliocaval deep vein thrombosis when 
post thrombolysis imaging identifies symptomatic residual stenosis. 
7. Post radiation venous stenosis. 
8. Symptomatic post-traumatic venous stenosis including those resulting from central venous catheters or 
transvenous device (e.g., pacemakers, defibrillators,) pacemaker leads or a history of abdominal and/or 
pelvic surgery. 
9. Salvage of thrombosed or stenotic symptomatic or limited function arteriovenous dialysis access 
fistulae or grafts with compromised venous outflow, failed angioplasty rapid restenosis, or vessel 
perforation. This may include treatment of trapping a life-threatening thrombus, an aneurysm or 
pseudoaneurysm that threatens the viability of the AV fistula or graft, or the treatment of a hemodialysis 
vascular access rupture that cannot be controlled through balloon tamponade. 
10. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome). 
11. Transvenous decompression of portosystemic shunts. 
12. Post-operative stenosis or venous narrowing due to repair of congenital cardiac disease, e.g. sinus 
venosus Atrial Septal Defect (ASD), discordant atrioventricular connection status post Mustard or 
Senning repair of Transposition of the Great Arteries (TGA). 
13. Pulmonary vein stenosis resulting from congenital malformation, extrinsic compression, sequelae of 
radiofrequency ablation (RFA), lung transplantation, or status post repair of Total Anomalous 
Pulmonary Vein Return (TAPVR).  
You can find these rules in Local Coverage Determination (LCD) Endovenous Stenting (L37893). 
 
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 $265 copayment for ambulance services. You can find this information 
on page 64 of the Plan's 2022 Evidence of Coverage (EOC). Also, a $300 copayment per day for days 1-5 for 
impatient hospital care. You can find this information on 83-86 of the Plan's 2022 Evidence of Coverage 
(EOC). Also, a $95 copayment for each outpatient diagnostic tests. You can find this information on pages 92-
94 of the Plan's 2022 Evidence of Coverage (EOC). Also, a $20 copayment physician/practitioner services 
office visit. You can find this information on pages 100-103 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 state that certain individual Tier 2 genetic tests are unlikely to impact therapeutic decision-making, 
directly impact treatment, outcome and/or clinical management in the care of the beneficiary and will be denied 
as not medically necessary. This list includes the MLH1 gene. You can find this information in the Centers for 
Medicare and Medicaid Services, Local Coverage Determination (LCD): Molecular Pathology Procedures 
(L35000). 
 
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 $50 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page(s) 30 to 33 of the Plan's 2021 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 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 $35 copayment for X-rays. You can find this information on page(s) 101 
of the Plan's 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules say that beginning January 1, 2020, the case-mix system of the HH PPS is replaced with the Patient-
Driven Groupings Model (PDGM). Under the PDGM, payments for 60-day episodes are replaced by a case-
mix adjusted payment for a period of care of up to 30 days. These 30-day periods of care are paid using one of 
432 Home Health Resource Groups (HHRG). The HHRGs combine claims and OASIS assessment data to 
group patients according to their admission source and timing, a clinical group assignment, the patients 
functional level and the presence of co-morbidities. You can find this rule in Definition and Uses of 
Health Insurance Prospective Payment System Codes (HIPPS Codes) located at 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ProspMedicareFeeSvcPmtGen/Downloads/hippsuses.pdf. 
 
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. 
 
Female external urinary collection devices are covered for beneficiaries who have permanent urinary 
incontinence when used as an alternative to an indwelling catheter. For female external urinary collection 
devices, more than one meatal cup (A4327) per week or more than one pouch (A4328) per day will be denied 
as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD): 
Urological Supplies (L33803). 
 
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). 
 
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 no payment may be made for the implantation of dorsal column or depth brain stimulators 
or services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Electrical Nerve Stimulators 
(160.7). 
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 for all beneficiaries receiving home health services in 2021 whose services will continue in 
2022, the home health agency (HHA) shall submit a Notice of Admission (NOA) with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. For example, if 
a period of care begins in 2021 and ends on January 10, 2022, the HHA submits an NOA with an admission 
date of January 11, 2022, and then submits a claim when the 30-day period of care is over. The HHA should 
submit the January 11, 2022, admission date on all subsequent claims until the beneficiary is discharged and 
another NOA is required. This is to ensure the claim is matched to the correct NOA and the correct receipt date 
is used for payment. You can find this information 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. 
 
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. This benefit includes 
preventive and comprehensive services. A gingival irrigation (D4921) is excluded from this benefit. A 
periodontal scaling and root planing (D4341) is covered under this benefit. You can find this information on 
pages 4-65 to 4-77 of the Plans 2022 Evidence of Coverage (EOC).