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 claim lines containing codes with an indicator of ''8'' in the PC/TC column of the MPFS and 
that are submitted in a place of service that is not inpatient hospital (POS 21) will deny. You can find this 
information in Medicare's Centers for Medicare & Medicaid Services (CMS)Medicare Physician Fee Schedule 
(MPFS). 
 
The rules say that when a physician performs a diagnostic test under arrangement to a hospital and the test and 
the interpretation are not separately billable, the interpretation cannot be billed by the physician. In this 
scenario, the hospital is the only entity that can bill for the diagnostic test which encompasses the 
interpretation. There is no POS code for the interpretation since a physician claim is not generated. You can 
find this information in the Medicare Claims Processing Manual, Chapter 13, Section 150. 
 
The rules say Professional Component (PC)/Technical Component (TC) Indicator 8 = Physician interpretation 
codes: This indicator identifies the professional component of clinical laboratory codes for which separate 
payment may be made only if the physician interprets an abnormal smear for hospital inpatient. This applies 
only to code 85060. No TC billing is recognized because payment for the underlying clinical laboratory test is 
made to the hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to 
hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory 
fee schedule payment for the clinical laboratory test. You can find this information in the Medicare Claims 
Processing Manual, Chapter 23, Section 50.6. 
 
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 please refer to the MolDX website www.palmettogba.com/MolDX for covered and excluded 
tests' specific coding and billing information. You can find this information in Medicare's Local Coverage 
Determination (LCD) MolDX: Molecular Diagnostic Tests (MDT) (L36807). 
 
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 claim lines containing codes with an indicator of ''8'' in the PC/TC column of the MPFS and 
that are submitted in a place of service that is not inpatient hospital (POS 21) will deny. You can find this 
information in Medicare's Centers for Medicare & Medicaid Services (CMS) Medicare Physician Fee Schedule 
(MPFS). 
 
The rules say that when a physician performs a diagnostic test under arrangement to a hospital and the test and 
the interpretation are not separately billable, the interpretation cannot be billed by the physician. In this 
scenario, the hospital is the only entity that can bill for the diagnostic test which encompasses the 
interpretation. There is no POS code for the interpretation since a physician claim is not generated. You can 
find this information in the Medicare Claims Processing Manual, Chapter 13, Section 150. 
 
The rules say Professional Component (PC)/Technical Component (TC) Indicator 8 = Physician interpretation 
codes: This indicator identifies the professional component of clinical laboratory codes for which separate 
payment may be made only if the physician interprets an abnormal smear for hospital inpatient. This applies 
only to code 85060. No TC billing is recognized because payment for the underlying clinical laboratory test is 
made to the hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to 
hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory 
fee schedule payment for the clinical laboratory test. You can find this information in the Medicare Claims 
Processing Manual, Chapter 23, Section 50.6. 
 
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 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) 46 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 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 in Chapter 3 on page 46 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 Somatic (Acquired) Cancer 
 
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). 
 
   b. The diagnostic laboratory test using NGS must have: 
 
    Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
    an FDA-approved or -cleared indication for use in that patients cancer; and, 
    results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this information in Medicare's 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.
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 a Medicare plan may restrict enrollees 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 an enrollees medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community-based 
services. You can find this rule at 42 CFR Section 422.112. 
 
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 38 to 39 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 state that A/B MACs (A) or (HHH), and DME MACs may not pay for oxygen equipment that is 
purchased on or after June 1, 1989 You can find this information in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 20, 
Section 30.6.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that if you qualify for Medicare oxygen equipment coverage, then for as long as you are 
enrolled, our plan will cover the rental of oxygen equipment. You can find this on page 81 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 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). 
 
   b. The diagnostic laboratory test using NGS must have: 
 
   - Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
   - an FDA-approved or -cleared indication for use in that patients cancer; and, 
   - results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 
You can find this rule in the National Coverage Determination (NCD) for 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 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 anesthesia time is defined as the period during which an anesthesia practitioner is present 
with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in 
the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing 
anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. 
Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In 
counting anesthesia time for services furnished, the anesthesia practitioner can add blocks of time around an 
interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care 
within the time periods around the interruption. 
 
Actual anesthesia time in minutes is reported on the claim. For anesthesia services furnished, the A/B MAC 
computes time units by dividing reported anesthesia time by 15 minutes. Round the time unit to one decimal 
place. The A/B MAC does not recognize time units for procedure code 01996 (daily hospital management of 
epidural or subarachnoid continuous drug administration). 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 50.G. 
 
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 cardiac event detection (CED) service is medically unnecessary if it offers little or no 
potential for new clinical data beyond that which has been obtained from a previous test, (e.g., a standard 
electrocardiogram has already established a diagnosis), or if other tests are better suited to obtain the clinical 
data relevant to the patient's condition. The CED should be coordinated with results from standard 
electrocardiograms (EKGs), Holter monitor tests, and stress tests. You can find this rule in the Local Coverage 
Determination (LCD) for Cardiac Event Detection (L33952). 
 
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 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 $75 copayment for outpatient diagnostic tests/diagnostic procedures. 
You can find this information on pages 86-87 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 say that coverage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of foot. This information must be retained in the treating 
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower 
Limb Prostheses (L33787) - Effective January 1, 2020 
 
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 PBT is considered reasonable in instances where sparing the surrounding normal tissue 
cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to the patient. 
Examples of such an advantage might be: 
 
    The target volume is in close proximity to one or more critical structures and a steep dose gradient outside 
the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s). 
    A decrease in the amount of dose inhomogeneity in a large treatment volume is required to avoid an 
excessive dose "hotspot" within the treated volume to lessen the risk of excessive early or late normal tissue 
toxicity. 
    A photon-based technique would increase the probability of clinically meaningful normal tissue toxicity by 
exceeding an integral dose-based metric associated with toxicity. 
    The same or an immediately adjacent area has been previously irradiated, and the dose distribution within 
the patient must be sculpted to avoid exceeding the cumulative tolerance dose of nearby normal tissue. 
 
PBT may offer dosimetric advantages as well as added complexity over conventional radiotherapy, 3D 
Conformal Radiation Therapy (3-D CRT) or Intensity Modulated Radiation Therapy (IMRT). Before applying 
PBT techniques, a comprehensive understanding of the benefits and consequences is required. In addition to 
satisfying at least one of the four selection criteria noted above, the radiation oncologist's decision to employ 
PBT requires an informed assessment of the benefits and risks including: 
 
    Determination of patient suitability for PBT allowing for reproducible treatment delivery 
    Adequate definition of the target volumes and OARs 
    Equipment capability, including ability to account for organ motion when relevant 
    Physician, physicist and staff training 
    Adequate quality assurance procedures. 
 
It is important to note that normal tissue dose volume histograms (DVHs) must be demonstrably improved with 
a PBT plan to validate coverage. Therefore, coverage decisions must extend beyond ICD-10 codes to 
incorporate additional considerations of clinical scenario and medical necessity with appropriate 
documentation. The final determination of the appropriateness and medical necessity for PBT resides with the 
treating radiation oncologist who should document the justification for PBT for each patient. 
 
You can find this information in the Local Coverage Determination (LCD) Proton Beam Therapy L35075.  
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 costs of certain ESRD laboratory services performed by either the ESRD facility or an independent 
laboratory are included in the composite rate and are not separately payable. These tests are either performed 
by the facility, in which case payment is included in the composite rate, or by an outside laboratory for the 
facility, in which case the laboratory bills the facility directly. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 8, Section 50.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.