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 providers 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 when administering multiple infusions, injections or combinations, report one "initial
"service code (CPT code 96360) unless protocol requires that two separate IV sites must be used. If more than
one "initial" service code (CPT code 96360) is to be billed on the same date of service (patient has to come
back for a separately identifiable service on the same day or has two IV lines per protocol), the service should
be reported utilizing the most appropriate modifier. Report the infusion code for "each additional hour" (CPT
code 96361) only if the infusion interval is greater than 30 minutes beyond the one-hour increment.
Utilization Parameters CPT code 96360 with/without CPT code 96361 will be paid once per session. Medicare
would not expect to see CPT code 96360 billed more frequently than once per day. You can find this in the
Local Coverage Determination (LCD)Hydration Therapy (L34960).
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 also say that certain data elements are required. Any claim with incomplete, missing, or invalid
information for all these elements may be returned as un-processable. You can find this rule in the Medicare
Claims Processing Manual, Chapter 1, Section 80.3.1.
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You
can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.
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 plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare
Managed Care Manual, Chapter 1, Section 20.2.
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, 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 page 9 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 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.
The 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 83 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 state that Medicare requires that services provided/ordered/certified be authenticated by the persons
responsible for the care of the beneficiary in accordance with Medicare's policies. The method used shall be a
handwritten or electronic signature. Stamped signatures are not acceptable. Providers should not add late
signatures to the medical record, (beyond the short delay that occurs during the transcription process) but
instead should make use of the signature authentication process. You can find this information in the Centers
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity
Manual, Chapter 3, 3.3.2.4.
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.
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 Advantage (MA) plan may offer coverage of a supplemental benefit only if it is 
medically necessary and additional to the benefit covered by original Medicare. A supplemental benefit is an 
item or service not covered by original Medicare, that is primarily health related and for which the MA plan 
must incur a non-zero direct medical cost. You can find this information in the Medicare Managed Care 
Manual, Chapter 4 - Benefits and Beneficiary Protections, 30.2  Supplemental Benefits Extending Original 
Medicare Benefits. 
 
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 general rule for the date of service (DOS) policy for either a clinical laboratory test or the
technical component of physician pathology service is to bill the date the specimen was collected as the date of
service. There are three possible exceptions to this rule:

1. For tests performed on stored specimens, when the specific criteria as noted in the manual are met, for
specimens stored less than or equal to 30 days, the DOS is when the testing was actually completed. If the
specimen was stored for more than 30 days, then the DOS is the date that the specimen was obtained from
storage. Specimens in the case of this exception must have been collected while the patient was undergoing a
hospital surgical procedure.
2. For samples of live tissue taken for chemotherapy sensitivity testing, the DOS is the date the testing was
performed, when the listed criteria are met. Specimens in this case must have been collected while the patient
was undergoing a hospital surgical procedure.
3. Lastly, there is an exception for Advanced Laboratory Tests (ADLT) performed on specimens which have
been collected in an outpatient hospital encounter. When specific criteria are met for these tests, the DOS is the
date the testing is performed.

You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 40.8.

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 viscosupplementation is considered not medically reasonable and necessary and will not be 
covered when a repeat series of injections is initiated prior to six months after completion of the previous 
course of treatment. You can find this information in the Local Coverage Determination (LCD) for Hyaluronan 
Acid Therapies for Osteoarthritis of the Knee (L35427). 
 
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 general rule for the date of service (DOS) policy for either a clinical laboratory test or the
technical component of physician pathology service is to bill the date the specimen was collected as the date of
service. There are three possible exceptions to this rule:
1. For tests performed on stored specimens, when the specific criteria as noted in the manual are met, for
specimens stored less than or equal to 30 days, the DOS is when the testing was actually completed. If the
specimen was stored for more than 30 days, then the DOS is the date that the specimen was obtained from
storage. Specimens in the case of this exception must have been collected while the patient was undergoing a
hospital surgical procedure.
2. For samples of live tissue taken for chemotherapy sensitivity testing, the DOS is the date the testing was
performed, when the listed criteria are met. Specimens in this case must have been collected while the patient
was undergoing a hospital surgical procedure.
3. Lastly, there is an exception for Advanced Laboratory Tests (ADLT) performed on specimens which have
been collected in an outpatient hospital encounter. When specific criteria are met for these tests, the DOS is the
date the testing is performed.
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual,
Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 40.8.
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 4 to 5 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 contract plan provider is an agent of the plan. Services and referrals obtained from a plan
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan,
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or
item is never covered, the plan does not have to hold the enrollee harmless.
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless.
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 160.
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 the following are covered indications for Duplex scans, Doppler Ultrasound with Spectrum 
Analysis, Ocular Pneumoplethysmography, and Periorbital Doppler: 
- Evaluation of patients with a cervical bruit 
- Evaluation of pulsatile neck masses 
- Evaluation of patients with hemispheric neurologic symptoms, including stroke, transient ischemic 
attack and amaurosis fugax 
- Follow-up of patients with proven carotid disease who are receiving medical therapy 
- Follow-up for postoperative patients following carotid endarterectomy, stenting or carotid to subclavian 
bypass 
- Evaluation of suspected subclavian steal syndrome 
- Evaluation of retinal arterial emboli 
- Evaluation of suspected carotid artery dissection or pseudoaneurysm 
- Evaluation of sudden and lateralizing neurologic deficit 
- Established or symptomatic coronary artery disease or cardiac valvular disease 
- "Drop attacks" or syncope when there are documented signs or symptoms consistent with vertebral 
basilar or carotid artery disease or insufficiency 
You can find this information in the Local Coverage Determination (LCD): Non-Invasive Cerebrovascular 
Arterial Studies (L35397). 
 
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 Medicare Advantage Contractors (MACs) pay for an initial hospital inpatient care service if 
a practitioner sees a patient in the emergency department and decides to admit the person to the hospital or 
place the patient in observation care. They do not pay for both E/M services. Also, they do not pay for an 
emergency department visit by the same practitioner on the same date of service. When the patient is admitted 
to the hospital via another site of service (e.g., hospital emergency department, physicians office, nursing 
facility), all services provided by the practitioner in conjunction with that admission are considered part of the 
initial hospital inpatient or observation care when performed on the same date as the admission. 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 30.6.9.1. 
 
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. 
 
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 Plan 
contract also says that says that the Plan covers dental services as a supplemental (extra) benefit. This benefit includes coverage for the prefabricated abutment  includes modification and placement (D6056) 2 every 
calendar year; 1 per tooth every 5 calendar years. Abutment supported porcelain/ceramic crown tooth (D6058) 
2 every calendar year; 1 per tooth every 5 calendar years. You can find this information on pages 95 to 96 of 
the Plan's 2023 Evidence of Coverage (EOC). The core buildup, including any pins when required (D2950) 3 
every calendar year; 1 per tooth every 5 calendar years. You can find this information on page 93 of the Plan's 
2023 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 Facet Joint Interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet ALL the following criteria: 
 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
These rules are found in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management 
(L38803). 
 
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.