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 for durable medical equipment items and supplies provided on a recurring basis, billing must
be based on prospective, not retrospective use. For products that are supplied as refills to the original order,
suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a predetermined
basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item
remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or
modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner
than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the
product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of
which delivery method is utilized. For all items that are provided on a recurring basis, suppliers are required to
have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers
must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented
refill request will be denied as not reasonable and necessary. Suppliers must not dispense a quantity of supplies
exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization
patterns on the part of their clients. Suppliers must verify with the treating practitioners that any changed or
atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three (3) -
month quantity at a time. You can find this rule in the Medicare Local Coverage Determination (LCD)
Transcutaneous Electrical Nerve Stimulators (TENS) (L33802).

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 cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if 
both of the following criteria are met: 
 
   1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 
   2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the 
beneficiary tolerated the selected device. 
 
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination (LCD) for  
 
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 F2 and F5 genetic tests are not considered to be clinically efficacious; therefore, testing 
is not medically necessary. You can find this information in the Local Coverage Determination (LCD): 
Molecular Pathology Procedures (L35000). 
 
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 a screening colonoscopy can become a diagnostic colonoscopy during the
procedure itself. A diagnostic colonoscopy is performed to explain symptoms identified by your physician (for
example, blood in stools, change in bowel movements, iron deficiency due to anemia, persistent abdominal
pain, etc.), because you have had a previous colonoscopy that resulted in removal of polyps, or other colorectal
related conditions. If your physician orders a diagnostic colonoscopy see "Outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers" or "Outpatient diagnostic
tests and therapeutic services and supplies" for cost share. You can see this on page 66 of the Plans 2023
Evidence of Coverage.

The Plan contract says that there is a $270 copayment for outpatient diagnostic imaging services. You can see
this on page 90 of the Plans 2023 Evidence of Coverage.

The Plan contract says that there is a $325 copayment for outpatient surgery services at a facility. You can see
this on page 96 of the Plans 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 rate, facility or nonfacility, that a physician service is paid under the Physician Fee Schedule is determined 
by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-
to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS 
code reflects the actual place where the beneficiary receives the face-to-face service and determines whether 
the facility or nonfacility payment rate is paid. You can find this in the Centers for Medicare and Medicaid 
Services, Internet-Only Manual, Publication Number 100-04, Medicare Claims Processing Manual, Chapter 12, 
Section 20.4.2. 
 
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 for code 92609, specific diagnosis codes must be reported. You can see this in the Medicare
Local Coverage Article (LCA) Billing and Coding: Speech Language Pathology (A52866).
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).

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 telephone alert systems are non-covered because they are emergency communication 
systems and do not serve a diagnostic or therapeutic purpose. You can find this rule in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 280.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that vagus nerve stimulation (VNS) is a pulse generator, similar to a pacemaker, that is 
surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the 
generator to the left vagus nerve. Electrical signals are sent from the battery-powered generator to the vagus 
nerve via the lead. These signals are in turn sent to the brain. The Food and Drug Administration (FDA) 
approved VNS for treatment of refractory epilepsy in 1997 and for resistant depression in 2005. 
 
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 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. 
 
The rules say that L5988 describes a separate product which provides either a single motion or a combination 
of motions generally attributed to functional movement of the lower limb during ambulation. The use of this 
code can be used to fully describe an additional feature of function not found in the prosthetic foot system. You 
can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496). 
 
The rules say that L5988 describes an endoskeletal pylon device that allows vertical shock reduction between 
the foot and pelvis during ambulation. The vertical shock reducing pylon feature of L5988 is a separate 
function from other products which use a piston/telescoping mechanism such as products described by L5781 
or L5782. The predicate product is the Total Shock that was manufactured by Century XXII International, 
Inc. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article 
(A52496). 
 
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 pneumatic compression device (PCD) coded as E0652, is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met: 
 The beneficiary has lymphedema of an extremity;  
 The coverage criteria for an E0650 or E0651 are met; 
 The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the 
limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed 
to improve with a four-week trial. 
 
A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. A PCD coded as E0652 used to treat lymphedema not extending onto the chest, trunk and/or 
abdomen or CVI is not eligible for reimbursement. A four-week trial of conservative therapy demonstrating 
failed response to treatment with an E0650 or E0651 is required.  
 
PCD related accessories (E0657) are eligible for reimbursement only when the appropriate, related base PCDs 
(E0652) meets the applicable coverage criteria for that type of PCD. If the base PCD is not covered, related 
accessories are not eligible for reimbursement.  
 
You can find this rule in the Local Coverage Determination for Pneumatic Compression Devices, L33829. 
 
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). 
 
The rules say SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable and 
necessary. You can find this rule at the Medicare Local Coverage Determination (LCD) L39464: Sacroiliac 
Joint Injections and Procedures. 
 
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 -KH modifier is billed for the initial claim, purchase, or first month of rental. The -KI 
modifier is billed for the second or third month rental. The -KJ modifier is billed for capped rental months four 
to 15. You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual 
Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 130.9. 
 
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 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. The Plan has a Point-of-Service (POS) option to cover certain 
out-of-network services. You can find this information on pages 43 and 47-48 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 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 the 
requested item or service but is limited to 1 procedure code per 36 plan months. You can find this information 
on page 66 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 If an agency chooses not to discharge and the patient returns to the agency in the same 30-
day period, the same period of care continues. However, if an agency chooses to discharge, based on an 
expectation that the beneficiary will not return, the agency should recognize that if the beneficiary does return 
to them in the same period, the discharge is not recognized for Medicare payment purposes. You can find this 
rule in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual Publication 100-04, 
Medicare Claims Processing Manual, Chapter 10, Section 10.1.14. 
 
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 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.  
 
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 the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2.  
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 state that a non-invasive peripheral venous study is covered when the documentation supports that 
the scan is reasonable and necessary. It is the providers responsibility to select codes carried out to the highest 
level of specificity. There is a list of diagnoses which support medical necessity. You can find this rule in the 
Local Coverage Article (LCA) A52993 - Billing and Coding: Non-Invasive Peripheral Venous Studies. 
 
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.