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 Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 there is a $0 copayment for preferred-brand Medicare-covered diabetic monitoring 
supplies. Non-preferred brands are not covered. You can find this information on pages 38 to 39 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving distance. You can 
find this information on pages 90-91 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 state that claims for Low Dose Computed Tomography (LDCT) for lung cancer screening that are not 
billed with: 
-Z87.891(personal history of tobacco use/personal history of nicotine dependence) 
-F17.210 (nicotine dependence, cigarettes, uncomplicated ) 
-F17.211 (nicotine dependence, cigarettes, in remission) 
-F17.213 (nicotine dependence, cigarettes, with withdrawal)  
-F17.218 (nicotine dependence, cigarettes, with other nicotine-induced disorders) 
-F17.219 (nicotine dependence, cigarettes, with unspecified nicotine-induced disorders) 
 
effective with dates of service on or after October 1, 2015, will be denied. You can find this information at the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 18, Section 220.4. 
 
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 state that effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement 
Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the following 
requirements are met: 
 
   a. Patient has: 
 
    -either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
    -not been previously tested with the same test using NGS for the same cancer genetic content, and 
    -decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
You can find this information in National Coverage Determination (NCD): Next Generation Sequencing (NGS) 
(90.2). 
 
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 Percutaneous Vertebral Augmentation (PVA) (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered in patients with BOTH the following: 
1. Inclusion criteria (ALL are required): 
a. Acute (fewer than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral 
Compression Fracture (VCF) (T1  L5), based on symptom onset, and documented by 
advanced imaging (bone marrow edema on magnetic resonance imaging (MRI) or bone-
scan/single-photon emission computerized tomography (SPECT)/computerized 
tomography (CT) uptake) 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog 
Scale (VAS) pain score of 8 or higher) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or higher) 
despite optimal non-surgical management (NSM) (ONE): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5 or higher) (with 2 or more 
of the following): 
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
2. Exclusion criteria (Can have NONE of the following): 
a. Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication 
i. Greater than three vertebral fractures per procedure ii. Allergy to bone cement or opacification agents 
iii. Uncorrected Coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
 
You can find these rules in Local Coverage Determination (LCD)Percutaneous Vertebral Augmentation (PVA) 
for Osteoporotic Vertebral Compression Fracture (VCF) L34228.  
 
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 76 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 Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers 60 one-way trips per year to Plan approved locations. You can find this information on pages 119-120 
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 that the Home Health Resource Group (HHRG) used to pay home health services are determined 
by the HH Grouper program. HHRGs are represented on claims in the form of Health Insurance Prospective 
Payment System (HIPPS) codes. The home health agency sends a HIPPS code on the claim, using revenue 
code 0023. Medicare systems combine claim data and Outcome and Assessment Information Set (OASIS) data 
and send the data to the HH Grouper to determine the HIPPS code used for payment. You can find this 
information in the Centers for Medicare and Medicaid Services, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 80. 
 
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 Outcome and Assessment Information 
Set (OASIS). The claims information and OASIS data elements are used to group 30-day periods of care into 
their case-mix groups. The home health agency receives a national, standardized 30-day payment of a 
predetermined rate for home health services unless CMS determines an intervening event warrants a new 30-
day period for purposes of payment. You can find this rule in the Centers for Medicare and Medicaid Services 
(CMS), Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 10.2 
and 10.7. 
 
The rules say that the determination of the patients primary and secondary home health diagnoses must be 
made by the assessing clinician based on the findings of the assessment, information in the medical record, and 
input from the physician. the secondary diagnoses include coexisting conditions actively addressed in the 
patients Plan of Care, and any comorbid conditions having the potential to affect the patients responsiveness 
to treatment and rehabilitative prognosis. The secondary diagnoses may or may not be related to a patients recent hospital stay but must have the potential to impact the skilled services provided by the agency. You can 
find this in the Outcome and Assessment Information Set OASIS-D Guidance Manual, Chapter 3, Section C.  
 
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. 
 
A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria (1) and (2): 
 
    1. Cannot self-propel in a standard wheelchair in the home; and 
 
    2. The beneficiary can and does self-propel in a lightweight wheelchair. 
 
You can find this rule in the Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788). 
 
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 percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 

1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g., rest, bracing). 
A. Both PVP and PVA will be considered reasonable and necessary when ALL of the following 
criteria are met: 
I. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral 
compression fracture (VCF) (T1- L5), based on symptom onset, and documented 
by advanced imaging demonstrating bone marrow edema on Magnetic resonance 
imaging (MRI) or bone-scan/single-photon emission computerized tomography 
(SPECT)/computerized tomography (CT) uptake AND 
II. The beneficiary is symptomatic and is hospitalized with severe pain (Numeric 
Rating Scale [NRS] or Visual Analog Scale [VAS] pain score of 8 or higher) OR 
is non-hospitalized with moderate to severe pain (NRS or VAS of 5 or higher) 
despite optimal non-surgical management (NSM) with one of the following: 
a. Worsening Pain or 
b. Stable to improved pain (but NRS or VAS of 5 or higher) when 2 or more 
of the following are present: 
i. Progression of vertebral body height loss 
ii. Greater than 25% vertebral body height reduction 
iii. Kyphotic deformity 
iv. Severe impact of VCF on daily functioning (Roland Morris 
Disability Questionnaire [RDQ] greater than 17) 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) L35130.  
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 
 
    Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management (e.g., narcotic and/or non- narcotic medication, physical 
therapy modalities) with and without methods of immobility (e.g., rest, bracing). 
        Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are 
met: 
            Acute (<6 wks) or subacute (6-12 wks)18,28,42 osteoporotic VCF (T1 L5), based on symptom onset, 
and documented by advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT 
uptake 1-3,8,26,43 and 
            The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
Visual Analog Scale [VAS] pain score = 8)4-7 or is non-hospitalized with moderate to severe pain (NRS or 
VAS =5) despite optimal non-surgical management (NSM)8 with one of the following: 
                Worsening Pain or 
                Stable to improved pain (but NRS or VAS =5) when 2 or more of the following are present: 
                    Progression of vertebral body height loss 
                    > 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] >17) 
 
You can find this information in the Local Coverage Determination (LCD) Percutaneous Vertebral 
Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) L34976. 
 
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 claims must specify whether equipment is rented or purchased. The RR modifier should be 
used when durable medical equipment (DME) is to be rented. The NU modifier should be used for new 
equipment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 130.9. 
 
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 I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. The Status Indicator P 
means that there are no payment amounts for these services. No separate payment should be 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. 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, Section 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 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 copayment for outpatient rehabilitation services. You can find this 
information on page(s) 48 of the Plan's 2023 Evidence of Coverage.