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 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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes 
coverage for 2 crowns per year. A core buildup is not listed as a covered procedure. You can find this 
information on page 79 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare 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. The Plan 
contract also says that you dont need to get a referral or prior authorization when you get care from out-of-
network providers. You can find this information on pages 34 to 35 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 a group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
 
1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the ICD-10 
code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over 
the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program 
including each of the following: 
   1. Use of an appropriate group 1 support surface, and 
   2. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
   3. Appropriate turning and positioning, and 
   4. Appropriate wound care, and 
   5. Appropriate management of moisture/incontinence, and 
   6. Nutritional assessment and intervention consistent with the overall plan of care 
2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis (refer to the 
ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable 
diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or 
nursing facility within the past 30 days 
 
You can find this information in the Local Coverage Determination (LCD): Pressure Reducing Support 
Surfaces - Group 2 (L33642). 
 
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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
   
The rules say that Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of 
the following qualified skilled services:  
 
1. Skilled nursing care;  
2. Physical therapy;  
3. Occupational therapy; or  
4. Speech pathology services.  
 
HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, 
home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 
and 409.45. 
 
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 if a home health agency provides fewer than the threshold of visits specified for the periods 
HHRG, they will be paid a standardized per visit payment. Such payment adjustments are called Low 
Utilization Payment Adjustments (LUPAs). On LUPA claims, nonroutine supplies will not be reimbursed in 
addition to the visit payments, since total annual supply payments are factored into all payment rates. If the 
claim for the LUPA is later adjusted such that the number of visits is equal to or greater than the threshold for 
the HHRG, payments will be adjusted to an HHRG basis, rather than a visit basis. If the LUPA period is the 
first in a sequence of adjacent periods or is the only period of care the beneficiary received, Medicare will make 
an additional add-on payment. Medicare will add to these claims an amount calculated from a factor 
established in regulation. This additional payment will be reflected in the payment for the earliest dated 
revenue code line representing a home health visit for skilled nursing, physical therapy, occupational therapy 
(after January 1, 2022), or speech-language pathology. One criterion that Medicare uses to determine whether a 
LUPA add-on payment applies is that the claim Admission Date matches the claim From Date. HHAs should 
take care to ensure that they submit accurate admission dates, especially if claims are submitted out of 
sequence. Inaccurate admission dates may result in Medicare systems returning LUPA claims where an add-on 
payment applies, but the add-on was paid inappropriately on a later dated period in the same sequence. 
Additionally, Medicare systems may return to the provider LUPA claims if the claim meets the criteria for a 
LUPA add-on payment but it contains no qualifying skilled service. In these cases, the HHA may add the 
skilled visit to the claim if it was omitted in error and re-submit the claim. Otherwise, the HHA may only re-
submit the claim using condition code 21, indicating a billing for a denial notice. You can find this rule in the 
Medicare Claims Processing Manual Chapter 10, Section 10.1.17. 
 
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 the following items are required to be filled out on submitted claims: 
- For services payable under the physician fee schedule and anesthesia services, enter the name and address, 
and ZIP code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than 
the patient's home or physician's office. Effective for claims received on or after April 1, 2004, enter the name, 
address, and ZIP code of the service location for all services other than those furnished in place of service 
home - 12. Effective for claims received on or after April 1, 2004, only one name, address and ZIP code may 
be entered in the block. If additional entries are needed, separate claim forms shall be submitted. Effective 
January 1, 2011, for claims processed on or after January 1, 2011, submission of the location where the service 
was rendered will be required for all POS codes. 
Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP code when billing 
for anti-markup tests. When more than one supplier is used, a separate CMS-1500 claim form shall be used to 
bill for each supplier. (See Pub. 100-04, chapter 1, 10.1.1.2 for more information on payment jurisdiction for 
claims subject to the anti-markup limitation.) 
 
Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory 
is billing, enter the place where the test was performed. 
 
You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual 
Chapter 26, Section 10.4. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
  
   
The rules state that neurogenic disorders can be distinguishable from myopathic disorders by a carefully 
performed EMG. For example, both polymyositis and ALS produce manifest weakness. The former carries a 
very different prognosis and treatment than the latter. An EMG is very valuable in making this distinction. 
Similarly, classification of nerve trauma into axonal vs. demyelinating categories, with corresponding 
differences in prognoses, are possible with EMG. Below is a list of common disorders where an EMG, in 
tandem with a properly conducted NCS, will be helpful in diagnosis: 
1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions. 
2. Radiculopathy - cervical, lumbosacral. 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary. 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies. 
5. Plexopathy - idiopathic, trauma, infiltration. 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here. 
7. At times, immediately prior to botulinum toxin injection, for localization. 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or 
chemodenervation. 
There may be other instances, not detailed here, where EMG may be of use. You can find this rule at the 
Medicare Local Coverage Determination (LCD) L35048, Nerve Conduction Studies and Electromyography. 
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). 
 
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 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). 
 
To be eligible for bariatric surgery the patient must have a body-mass index (BMI) = 35, and at least one co-
morbidity related to obesity. Further, the documentation must clearly demonstrate the failure of reasonable 
non-invasive/non-surgical treatments for obesity with which the beneficiary has been compliant. The following 
are considered to be the minimum specifications to be documented in the patient record in order to demonstrate 
the beneficiary has been previously unsuccessful with medical treatment for obesity as required: 
 
1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but 
is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-
management program that is supervised by a physician or other health care professionals for a minimum of four 
consecutive months. The weight-management program must include monthly documentation of patients 
weight and body mass index (BMI), current dietary regimen and physical activity (e.g., exercise program). 
2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to 
meet this requirement. 
3. A thorough multidisciplinary evaluation is required within the previous six months which includes all of the 
following: 
a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the 
proposed procedure(s) 
b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiarys 
primary care physician that includes both a recommendation for bariatric surgery as well as a medical 
clearance for the proposed bariatric surgery c. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a 
statement regarding motivation and ability to follow post-surgical requirements 
d. a nutritional evaluation by a physician or registered dietician. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage Article 
(LCA): Billing and Coding: Bariatric Surgery Coverage (A53028). 
 
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 $350 copayment for in-network outpatient surgery. You can find this 
information on page(s) 83 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 $35 copayment for in-network hearing services. You can find this 
information on page(s) 75 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 state that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the place of 
service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face-to-face 
service. For example, if the physicians face-to-face encounter with a patient occurs in the office, the correct 
POS code on the claim, in general, reflects the 2-digit POS code 11 for office. In these instances, the 2-digit 
POS code (Item 24B on the claim Form CMS-1500) will match the address and ZIP entered in the service 
location (Item 32 on the 1500 Form)  the physical/geographical location of the physician. However, there are 
two exceptions to this general rule  these are for a service rendered to a patient who is a registered inpatient or 
an outpatient of a hospital. In these cases, the correct POS code -- regardless of where the face-to-face service 
occurs -- is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate 
outpatient hospital POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus 
or on campus). You can find these rules in Medicare Claims Processing Manual Chapter 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 state that abnormal breathing events in sleep apnea syndromes include apnea, hypopnea and 
respiratory effort related arousals (RERA). Apnea is a cessation of airflow for at least 10 seconds. Hypopnea is 
an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal 
movement or airflow as compared to baseline, and with at least a 4% decrease in oxyhemoglobin saturation. 
RERA is defined as a period during sleep lasting at least 10 seconds during which severe narrowing of the 
upper airways with increasing respiratory efforts leads to electroencephalographic arousal from sleep without 
an appreciable reduction in airflow and oxygen saturation.  
 
Apneas can be classified as central, obstructive or mixed based on the presence of respiratory effort during the 
event. In obstructive apnea events, respiratory effort continues in the absence of airflow while in central apnea 
events, both airflow and respiratory effort are simultaneously absent. Mixed apnea events contain respiratory 
effort only during a portion of the apnea event.  
 
For a diagnosis of OSA to be made, the following criteria must be met:  
 
A. Prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating physician to assess the 
patient for OSA which must include, at a minimum, the following: 
 
    Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, 
choking or gasping during sleep, morning headaches; and, 
    Epworth Sleepiness Scale; and, 
    Physical examination that documents body mass index, neck circumference and a focused cardiopulmonary 
and upper airway system evaluation. 
 
B. The patient has a covered sleep test that meets either of the following criteria:  
 
    The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 
events per hour with a minimum of 30 events; or, 
    The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:  
        Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
        Hypertension, ischemic heart disease, or history of stroke  
 
You can find this information in the Local Coverage Determination (LCD) Polysomnography and Sleep 
Testing L33405. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.