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 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 & 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 pages 66-67 of the Plans 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 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 The following clinical indications apply to the Computerized Axial Tomography (CT or 
CAT) of the thorax: 
 
1. Evaluation of pulmonary, mediastinal, pleural and chest wall infections and their complications, 
2. Detection and characterization of mediastinal neoplasms and other processes, 
3. Assessment of cardiopulmonary failure or insufficiency, 
4. Diagnosis and/or staging of neoplastic and hematologic processes arising in the thorax or with potential 
involvement of the thorax, 
5. Detection and determination of nature and extent of cardiovascular abnormalities such as, but not limited to 
aneurysm, dissection, embolism, thrombosis, congenital anomalies, postoperative complications and sequelae 
of atherosclerotic disease, 
6. For assessing and/or guiding drainage of pulmonary or pleural fluid collections such as abscess, empyema, 
effusion or pneumothorax, 
7. For characterizing and follow-up evaluation of interstitial and alveolar lung disease due to idiopathic, 
allergic, collagen-vascular, environmental or other causes, 
8. For evaluating thoracic sequelae of remote processes including, but not limited to, pancreatitis, 
gastrointestinal perforation and other processes, 
9. For assessing injury, potential injury or thoracic sequelae after trauma, burn, surgery, transplantation, 
radiation therapy, chemotherapy or invasive procedure such as pacemaker placement, chest tube placement or 
mechanical ventilation, 
10. Evaluation of the patient with symptoms that may be arising from the chest, or be referred to the chest 
including but not limited to cough, hemoptysis, chest pain, abdominal pain and others, 
11. To further characterize a suspected abnormality detected by another imaging test, 
12. Evaluation of a patient with myasthenia gravis to rule out thymic tumors, 
13. Performance of CT-guided biopsies and drainage, 14. Procedures when fluoroscopy is inadequate. 
 
You can find this information in the Local Coverage Determination (LCD) L33459: Computerized Axial 
Tomography (CT), Thorax. 
 
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 apheresis is covered for the following indications: 
1. Plasma exchange for acquired myasthenia gravis; 
2. Leukapheresis in the treatment of leukemia; 
3. Plasmapheresis in the treatment of primary macroglobulinemia (Waldenstrom); 
4. Treatment of hyperglobulinemias, including (but not limited to) multiple myelomas, cryoglobulinemia 
and hyperviscosity syndromes; 
5. Plasmapheresis or plasma exchange as a last resort treatment of thromobotic thrombocytopenic purpura 
(TTP); 
6. Plasmapheresis or plasma exchange in the last resort treatment of life threatening rheumatoid vasculitis; 
7. Plasma perfusion of charcoal filters for treatment of pruritis of cholestatic liver disease; 
8. Plasma exchange in the treatment of Goodpasture's Syndrome; 
9. Plasma exchange in the treatment of glomerulonephritis associated with antiglomerular basement 
membrane antibodies and advancing renal failure or pulmonary hemorrhage; 
10. Treatment of chronic relapsing polyneuropathy for patients with severe or life threatening symptoms 
who have failed to respond to conventional therapy; 
11. Treatment of life threatening scleroderma and polymyositis when the patient is unresponsive to 
conventional therapy; 
12. Treatment of Guillain-Barre Syndrome; and 
13. Treatment of last resort for life threatening systemic lupus erythematosus (SLE) when conventional 
therapy has failed to prevent clinical deterioration. 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 110.14. 
 
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 $25 copayment for each in-network Medicare-covered individual 
therapy session. You can find this information on page 84 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay a $20 copayment for in-network Medicare-covered non-
radiological diagnostic services. You can find this information on page 78 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 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).  
 
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 $750 deductible which applies to certain items and services. The Plan 
deductible applies to the cataract surgery. You can find this information on page 44 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 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 & Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Effective January 1, 2005, hospitals paid under the Outpatient Prospective Payment System (OPPS) 
(bill types 12X and 13X) that report procedure codes that require the use of devices must also report the 
applicable Healthcare Common Procedure Coding System (HCPCS) codes and charges for all devices that are 
used to perform the procedures where such codes exist and are designated with a status indicator of "N" (for 
packaged payment) or "H" (for pass-through device payment) in the OPPS Addendum B that applies to the date 
of service. You can find this rule in the Centers for Medicare and Medicare Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 61.1. 
 
The rules say effective for claims with dates of service July 1, 2007, and after, the non-Outpatient Prospective 
Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. This 
integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital claims, 
through a single integrated OCE eliminating the need to update two separate OCE software packages on a 
quarterly basis. You can find this rule in the Centers for Medicare and Medicare Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 40.1.  
 
The rules say that Edit 98 is when a pass-through device is present without an associated, required procedure. 
You can find this information in the Integrated OCE Centers for Medicare and Medicaid Services (CMS) 
Specifications V24.2. 
 
The rules say that HCPCS code C1761 should always be billed with one of the following CPT codes: 92928, 
92933, 92943, C9600, C9602, and C9607. You can find this information in Centers for Medicare & Medicaid 
Services (CMS), Offset Codepair sheet listed in the IOCE Quarterly Data Files V242.R0 under the Report-
Table folder. 
 
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 modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
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. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. 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. 
 
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 20% coinsurance for durable medical equipment (DME) and related 
supplies.  You can find this information on page(s) 55-56 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 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 $325 copayment for Inpatient services in a psychiatric hospital. The 
enrollee must pay $325 per day, days 1-3, for each inpatient hospital admission. You can find this information 
on page(s) 64 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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that GUARDANT360 remains covered for patients with non-CNS originated solid tumors who 
meet the criteria of NCD 90.2 when certain conditions are met. CPT Codes include code 81479. You can find 
this rule in the Local Coverage Article for the Billing and Coding of Guardant360, A58192. 
 
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) 71 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 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 $300 copayment for outpatient diagnostic tests, including complex 
imaging.  You can find this information on page(s) 64-65 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 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 & 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 only the 
items and services listed in the dental rider. A surgical extraction (D7210) may be covered by the enrollees 
dental benefits. Prior authorization may be required. You can find this information on pages 77-78 of the Plans 
2023 Evidence of Coverage (EOC).