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 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 state that the single photon emission computed tomography (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
- stress fracture. 
- spondylosis. 
- infection (e.g., discitis). 
- tumor (e.g., osteoid osteoma). 
- analyze blood flow to an organ, as in the case of myocardial viability. 
- differentiate ischemic heart disease from dilated cardiomyopathy. 
You can find this information in National Coverage Determination (NCD): Single Photon Emission Computed 
Tomography (SPECT) (220.12). 
 
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 definitive urine drug testing (UDT) is reasonable and necessary for the following 
circumstances: 
 
1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
2. Definitively identify specific drugs in a large family of drugs; 
3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
6. Rule out an error as the cause of a presumptive UDT result; 
7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
You can find this rule in the Local Coverage Determination (LCD) - Lab: Controlled Substance Monitoring 
and Drugs of Abuse Testing (L35724). 
 
The rules say that definitive UDT may be reasonable and necessary based on patient specific indications, 
including historical use, medication response, and clinical assessment, when accurate results are necessary to 
make clinical decisions. The clinicians rationale for the definitive UDT and the tests ordered must be 
documented in the patients medical record. You can find this rule in the Local Coverage Determination (LCD) 
- Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L35724). 
 
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 that facet joint interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet all the following criteria: 
 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale; and 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated); and 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst); and 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
You can find this information in the Local Coverage Determination (LCD) L35936: Facet Joint Interventions 
for Pain Management. 
 
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 Facet Joint Interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria: 
 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale; AND 
2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst); AND 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or 
four-level procedure bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. A session is a time period, which includes all procedures that 
are performed during the same day. You can find these rules in Local Coverage Determination (LCD): Facet 
Joint Interventions for Pain Management (L34892). 
 
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 any of the three below options must be implemented in a manner not inconsistent with the 
state emergency and pandemic plan for patient surges during the COVID-19 public health emergency (PHE). 
Prior to seeking participation in Medicare or Medicaid, freestanding emergency departments (EDs) should 
contact their state health department and state survey agency to determine the role of these facilities during the 
COVID-19 public health emergency (PHE). 
1. Licensed independent freestanding hospital-affiliated emergency departments 
2. Licensed independent freestanding emergency departments enrolling as a Medicaid Clinic 
3. Licensed independent freestanding emergency departments becoming a hospital 
 
A licensed independent freestanding ED choosing to enroll as a hospital during the COVID-19 PHE must 
initially meet and continue to meet the Medicare hospital Conditions of Participation, to the extent not waived, 
and would receive hospital payments from Medicare based on the care provided. It is important to note that 
temporarily enrolling as a hospital means the licensed independent freestanding ED may provide inpatient and 
outpatient care, as needed during the PHE. Additionally, the licensed independent ED enrolled as a hospital 
will be required to provide a Medicare Outpatient Observation Notice (MOON) (CMS-10611) to all Medicare 
beneficiaries, including, when applicable, Medicare Advantage enrollees informing beneficiaries that they are 
outpatients receiving observation services and are not inpatients of the hospital. You can find these rules in 
Center for Clinical Standards and Quality / Quality, Safety, and Oversight Group Guidance for Licensed 
Independent Freestanding Emergency Departments (EDs) to Participate in Medicare and Medicaid during the 
COVID-19 Public Health Emergency (QSO-20-27-Hospital). 
 
The rules state that to receive payment for covered items or services from either Medicare or a Medicare 
beneficiary, a supplier or provider must be enrolled in the Medicare program. You can find this rule in 42 Code 
of Federal Regulations (CFR) Section 424.505.  
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 evaluation and management services occur on the day of surgery, the physician bills 
using modifier -57, not -25. The -57 modifier is not used with minor surgeries because the global period for 
minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the 
minor procedure is typically done immediately before the service, it is considered a routine preoperative 
service and a visit or consultation is not billed in addition to the procedure. You can find this rule in Medicare 
Claims Processing Manual Chapter 12, Section 40.2. 
 
The rules state that procedure code 31624  diagnostic bronchoscopy  has a global surgery value of 000, 
meaning an endoscopic or minor procedure with related preoperative and postoperative relative values on the 
day of the procedure only included in the fee schedule payment amount. Evaluation and management services 
on the day of the procedure are generally not payable. You can find this rule in the 2023 National Physician 
Fee Schedule Relative Value File. 
 
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 laboratory providers who bill molecular diagnostic tests must register test services on the 
DEX Diagnostics Exchange. You can find this rule in the Local Coverage Determination (LCD) - MolDX: 
Molecular Diagnostic Tests (MDT) (L35025). 
 
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 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). 
 
The rules say that Cardiac computed tomographic angiography (CCTA), also known as computed tomography 
(CT) of the heart and coronary arteries or multidetector computed cardiac tomography (MDCT), is considered 
reasonable and necessary for the evaluation of suspected symptomatic coronary artery disease (CAD) and for 
the detection of structural and morphologic intra- and extra-cardiac conditions. Evaluation of acute chest pain, 
unexplained dyspnea or symptoms suggesting angina pectoris (such as jaw pain) when there is: 
 
1.Intermediate pre-test probability of CAD; and 
2.No electrocardiogram (EKG) changes to suggest acute myocardial injury or ischemia; and 
3.Normal initial cardiac markers; and 
4.Patients with intermediate risk and a discordant clinical situation (e.g., ongoing ischemic symptoms, normal 
stress test). 
 
You can find this information in the Local Coverage Determination (LCD) L33423: Cardiac Computed 
Tomography and Angiography. 
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 required type of bill is a four-digit alphanumeric code gives three specific pieces of 
information after a leading zero. CMS will ignore the leading zero. CMS will continue to process three specific 
pieces of information. The second digit identifies the type of facility. The third classifies the type of care. The 
fourth indicates the sequence of this bill in this particular episode of care. It is referred to as a "frequency" 
code. Codes used for Medicare claims are available from Medicare contractors. Codes are also available from 
the NUBC (www.nubc.org) via the NUBC's Official UB-04 Data Specifications Manual. You can find this rule 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 25, Section 75.1. 
 
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 STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. See 
the OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/ for identification of STV-packaged 
codes. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims Processing 
Manual Chapter 4 - Part B Hospital, Section 10.4, C, 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 code 81273 (KIT) is considered medically necessary only for the diagnosis of mastocytosis. 
You can find this rule in the Local Coverage Article (LCA) for Billing and Coding: Molecular Pathology 
Procedures (A56199). 
 
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. 
A custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive sleep apnea 
(OSA) is covered if criteria A - D are met. 
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-
related Policy Article for applicable diagnoses. 
B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3):  
1. 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, 
2. 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:  
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
b. Hypertension, ischemic heart disease, or history of stroke; or, 
3. If the AHI> 30 or the RDI> 30 and meets either of the following(a or b):  
a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
b. The treating practitioner determines that the use of a PAP device is contraindicated. 
C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who 
performed the clinical evaluation in criterion A.) 
D. The device is provided and billed for by a licensed dentist (DDS or DMD). 
If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. You can find this rule in Local Coverage Determination (LCD) Oral Appliances for 
Obstructive Sleep Apnea L33611. 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 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 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 a type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An 
Excludes1 note indicates that the code excluded should never be used at the same time as the code above the 
Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form 
versus an acquired form of the same condition. You can find this information in the International Classification 
of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting, 
FY 2022. 
 
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.