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/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 all line items for the same beneficiary, same NPI, and same date of service shall be subject to 
NCCI Procedure-to-Procedure (PTP) edits. If the correct coding modifier indicator (CCMI) of a PTP edit is 
"0", the Column Two code is not eligible for payment even if an NCCI PTP-associated modifier is 
appropriately appended to one of the codes. If the CCMI of a PTP edit is "1", the edit may be bypassed, and the 
Column Two code of the edit may be eligible for payment if an NCCI PTP-associated modifier is appropriately 
appended to one of the codes. 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 20.9.1.1. 
 
The rules say that the Professional Component (PC)/Technical Component (TC) Indicator of 1 identifies codes 
that describe diagnostic tests, e.g., pulmonary function tests, or therapeutic radiology procedures, e.g., radiation 
therapy. These codes generally have both a professional and technical component. Modifiers 26 and TC can be 
used with these codes. The total RVUs for codes reported with a 26 modifier include values for physician 
work, practice expense, and malpractice expense. The total RVUs for codes reported with a TC modifier 
include values for practice expense and malpractice expense only. 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 50.6. 
 
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 Food and Drug Administration (FDA)-approved hypoglossal nerve neurostimulation is 
considered medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea 
when all of the following criteria are met: 
1. Beneficiary is 22 years of age or older; and 
2. Body mass index (BMI) is less than 35 kg/m2; and 
3. A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and 
4. Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% of the 
total apnea-hypopnea index (AHI)); and 
5. AHI is 15 to 65 events per hour; and 
6. Beneficiary has documentation that demonstrates continuous positive airway pressure (CPAP) failure 
(defined as AHI greater than 15 despite CPAP usage) or CPAP intolerance (defined as less than 4 hours per 
night, 5 nights per week or the CPAP has been returned) including shared decision making that the patient was 
intolerant of CPAP despite consultation with a sleep expert; and 
7. Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy 
(DISE) procedure; and 
8. No other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per 
standardized tonsillar hypertrophy grading scale). 
You can find this information in the Local Coverage Determination (LCD): Hypoglossal Nerve Stimulation for 
the Treatment of Obstructive Sleep Apnea (L38387). 
 
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 if one laboratory procedure evaluates multiple genes using a next 
generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with 
algorithmic analysis, or proprietary laboratory analysis CPT code. You can find this rule in the Centers for 
Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare 
Services, Chapter X(F). 
 
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 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 12 one-way trips per year. You can find this information on pages 4-53 to 4-54 of the Plans 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 417.414. 
 
The rules say that Medicare may cover medically accepted off-label uses for Food and Drug Administration 
(FDA) approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of 
compendia which define if a use is medically accepted. The off-label use must be supported in one or more of 
these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one 
or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or 
equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state 
to be reasonable and necessary. You can find these rules and the list of the Medicare-recognized compendia in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 50.4.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the CxBladder test is now covered utilizing the reasonable and necessary guidelines as 
outlined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A) which states that no Medicare 
payment shall be made for items or services which are not reasonable and necessary for the diagnosis or 
treatment of illness or injury. Therefore, CxBladder is not addressed in the LCD or billing and coding article. 
You can find this in the Local Coverage Article for Response to Comments: Biomarkers for Oncology, A58529 
(eff 12/13/20). 
 
The rules say that screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be 
ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or 
treats a beneficiary for a specific medical problem and who uses the results in the management of the 
beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are 
not reasonable and necessary. You can find this rule in 42 CFR, Section 410.32. 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 does not pay for over-the-counter (OTC) items, including non-prescription drugs. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 40.2. 
 
As of April 4, 2022, and until the end of the COVID-19 Public Health Emergency (PHE), people with 
Medicare Part B can get up to eight free over-the-counter tests for the month of April any time before April 30, 
and can get another set of eight free over-the-counter tests during each subsequent calendar month through the 
end of the COVID-19 PHE. Medicare coverage and payment begins on April 4, 2022, and is available for up to 
eight over-the-counter COVID-19 tests per calendar month you receive from a participating pharmacy or health 
care provider after the initiative starts. Medicare will not provide payment for over-the-counter COVID-19 tests 
obtained prior to April 4, 2022. You can find this information online at 
https://www.cms.gov/newsroom/factsheets/medicare-covers-over-counter-covid-19-tests. 
 
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 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 60 one-way trips with each one-way trip not exceeding 75 miles of driving distance. You can find 
this information on page 4-83 of the Plans 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 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 100 one-way ground transportation trips per calendar year. Trips must be to or from Plan-
approved health-related locations and must not exceed 60 miles based on the most efficient route. You can find 
this information on pages 83-84 of the Plans 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 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 pages 38-43 of the Plan's 2021 
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 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. These rules apply to all categories listed in the contract's 
Benefits Chart. You can find this information on pages 25-30 and 40-41 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 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 7-8 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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that invasive procedures for the treatment of varicose veins are considered medically reasonable 
and necessary when ALL of the following criteria have been met:  
 An evaluation of the patient has been performed including a history and physical examination, the 
CEAP clinical classification and the revised Venous Clinical Severity Score (VCSS), AND 
 A duplex scan of the deep and superficial venous systems supports the examination findings,
3
 AND 
 A duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in 
the saphenous, or perforator veins is 500 milliseconds or greater
3
 and absence of deep venous 
obstruction,
 
AND 
 The documentation supports signs and/or symptoms that interfere with activities of daily living and/or 
quality of life, AND 
 The CEAP clinical classification is C1 to C6 with the following criteria: 
o Treatment of C1 disease (telangiectasia and their feeding reticular veins) is considered 
medically reasonable and necessary for patients with spontaneous and/or traumatic venous 
hemorrhage. 
o For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation 
of a period of conservative therapy (2 to 4 weeks) including graduated compression 20-30 
mmHg or greater, ambulation, elevation, and avoiding prolonged sitting and standing. 
o For patients who meet any one of the following criteria, the mandatory conservative therapy 
prior to the invasive procedure may be waived.  
 VCSS 6 
 C4-C6 disease (skin changes assigned to venous disease, healed venous leg ulceration, 
and active venous leg ulceration) 
 Hemorrhage 
 Recurrent superficial thrombophlebitis 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 does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 to receive coverage for hearing aids you must use a provider in the Plans hearing aid 
network. You can find this information on page 70 of the Plan's 2021 Evidence of Coverage.