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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that brakes other than hand operated brakes, provided at the same time as a walker (E0141, 
E0143, E0149) may not be billed separately to the DME MACs or the beneficiary upon initial issue. However, 
if billed separately upon initial issue the brakes must be billed using A9900, and the brakes will deny as not 
separately payable. HCPCS code E0159 (Brake attachment for wheeled walker, replacement, each) is 
applicable for replacement brakes only. You can find the rules in Local Coverage Article 
Walkers - Policy Article A52503. 
 
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 manual wheelchair for use inside the home may be covered if the enrollee has a mobility 
limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of 
daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in 
the home. The mobility limitation must be unable to be sufficiently resolved by the use of an appropriately 
fitted cane or walker. You can find this information in the Local Coverage Determination (LCD): Manual 
Wheelchair Bases (L33788). 
 
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 say that the Physician Fee Schedule Status Indicator N means that the code in question is non-
covered. 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, 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 new 36-month rental period does not start in the following situations: 
 
Replacing equipment due to malfunction, wear and tear, routine maintenance, repair 
Providing different equipment based on a treating practitioner order or beneficiary request for an upgrade 
Break-in-need (see BREAK-IN-SERVICE below) 
Break-in-billing (see BREAK-IN-SERVICE below) 
Changing suppliers 
 
You can find this information in the Local Coverage Article Oxygen and Oxygen Equipment - Policy Article 
A52514. 
 
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 state that special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that 
has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health 
or overall function of the enrollee. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. You can find a complete list of covered 
chronic conditions on pages 59 through 60 of the Plans 2022 Evidence of Coverage (EOC). You can find 
additional coverage criteria on page 102 of the Plans 2022 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. You can find this information on page 45 of the Plans 2022 
Evidence of Coverage (EOC). Furthermore, out-of-network providers may be used if the treating physician can 
attest that discontinuing care would worsen or otherwise interfere with your condition and/or anticipated 
outcomes. You can find this information on pages 7 and 8 of the Plans Continuity and Transition of Care 
Guidelines document.
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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 290(3). 
 
The rules also say that inserts and other shoe modifications for CPT codes L3000-L3595 are covered if they are 
on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper 
functioning of that brace. 
 
You can find this information at Local Coverage Article for Orthopedic Footwear A52481. 
 
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 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 42 to 49 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 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 per calendar year but each one-way trip must not exceed 50 miles of driving 
Distance. You can find this information on pages 4-55 to 4-56 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 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 41 to 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 state that ESRD claims for hemodialysis with dates of service on or after July 1, 2010, must indicate 
the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the 
month. One of three modifiers is required to be reported on the latest line item date of service billing for 
hemodialysis revenue code 0821. It may be reported on all revenue code 0821 lines at the discretion of the 
provider. Modifier V5 should be reported for vascular catheter, V6 for arteriovenous graft, or V7 for 
arteriovenous fistula. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.9(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 meet Medicare's criteria for coverage, there needs to be 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline using same scale for at least three months, but 
because the procedure was only done two months ago there is no documentation that the member has had at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline 
using same scale for at least three months. You can find this information in Medicare's Local Coverage 
Determination (LCD): Epidural Steroid Injections for Pain Management (L38994). 
 
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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made 
based upon the specifics of each persons medical condition. There must be enough detailed information in the 
medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination 
(LCD): Respiratory Assist Devices (L33800). 
 
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 Group two power operated vehicles (POVs) (K0806, K0807, K0808) have added 
capabilities that are not needed for use in the home. Therefore, if a Group two POV is provided it will be 
denied as not reasonable and necessary. 
You can find these rules in the Local Coverage Determination (LCD) Power Mobility Devices, L33789. 
 
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 initial treatment left prefrontal repetitive transcranial magnetic stimulation (rTMS) of the 
brain is considered medically necessary for use in an adult who meets all four of the following criteria: 
1. Has a confirmed diagnosis of severe major depressive disorder (MDD) single or recurrent episode. 
2. One or more of the following: 
- Resistance to treatment with psychopharmacologic agents as evidenced by a lack of a clinically 
significant response to at least a single trial of psychopharmacologic agents in the current 
depressive episode; or 
- Inability to tolerate psychopharmacologic agents as evidenced by two trials of 
psychopharmacologic agents from two different agent classes: or 
- History of response to rTMS in a previous depressive episode; or 
- A history of response to electroconvulsive therapy (ECT) in a previous or current episode or an 
inability to tolerate ECT, or is a candidate for, but has declined ECT and rTMS is considered a 
less invasive treatment option. 
3. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an 
adequate frequency and duration without significant improvement in depressive symptoms as 
documented by standardized rating scales that reliably measure depressive symptoms. 
4. The order for treatment (or retreatment) is written by a psychiatrist (MD or DO), who has examined the 
patient and reviewed the record. The treatment shall be given under direct supervision of a qualified 
physician (physician present in the area and immediately available, but does not necessarily personally 
provide the treatment). 
 
You can find these rules in Local Coverage Determination (LCD) Repetitive Transcranial Magnetic 
Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L34998). 
 
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 not covered because these are emergency communications 
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 say that computed tomography (CT) scans are covered if there is literature to support its use for the 
patients condition and the scan is reasonable and necessary for the patient. 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 220.1(A). 
 
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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 290(3). 
 
The rules say that inserts and other shoe modifications (L3000, L3001, L3002, L3003, L3010, L3020, L3030, 
L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, 
L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, 
L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and 
L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically 
necessary for the proper functioning of the brace. 
 
You can find this information at Local Coverage Article (LCA): Orthopedic Footwear-Policy Article 
(A52481). 
 
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.