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 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.  
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 enrollees must pay a $90 copayment for emergency services. It is also noted that outpatient 
observation does not have a copayment. You can find this on pages 76-79 of the 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
The rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and 
necessary. You can find this rule in Local Coverage Determination (LCD) Cold Therapy L33735. 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 74 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 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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) (L35160) and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) (A57526). 
 
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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 61 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 rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. 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 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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 has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information in the Plan's Part B Preferred Drug List.
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. 
 
Medicare rules state that a total electric hospital bed is not covered. The height adjustment feature is a 
convenience feature. You can find this rule in the Centers for Medicare and Medicaid Services, Durable 
Medical Equipment Administrative Contractor Local Coverage Determination L33820, Hospital Beds and 
Accessories (effective October 1, 2015). 
 
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 fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, 
L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, 
L5858) is covered for beneficiaries whose functional level is 3 or above. 
 
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. 
 
A flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
 
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
You can find this information in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not 
describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5974, 
L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The use of additional feature L-codes may also 
depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD.  
 
You can find this information in Local Coverage Article: Lower Limb Prostheses (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 state that Epidural steroid injection (ESI) will be considered medically reasonable and necessary 
when the following requirements are met: 
 
1. History, physical examination, and concordant radiological image-based diagnostic testing that supports one 
of the following: 
 
a. Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal 
or central spinal stenosis, OR Post-laminectomy syndrome, OR Acute herpes zoster associated pain. 
AND 
 
b. Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact 
quality of life or function. An objective pain scale or functional assessment must be performed at 
baseline (prior to interventions). The same scale* must be used at each follow-up for assessment of 
response. 
AND 
 
c. Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute 
herpes zoster refractory to conservative management where a four (4) week wait is not required. 
 
The ESIs must be performed under computed tomography (CT) or fluoroscopy image guidance with contrast 
unless the patient has a documented contrast allergy or pregnancy where ultrasound guidance without contrast 
may be considered. 
 
Transforaminal ESIs (TFESIs) involving a maximum of two (2) levels in one spinal region are considered 
medically reasonable and necessary. It is important to recognize that most conditions would not ordinarily 
require ESI at two (2) levels in one spinal region.  
Caudal ESIs and interlaminar ESIs (ILESIs) involving a maximum of one level are considered medically 
reasonable and necessary. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
Epidural Steroid Injections for Pain Management L33906 
 
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 page 30 to 31 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 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 10% coinsurance for Medicare Part B prescription drugs. You can find 
this information on pages A37-A38 of the Plan's 2022 to 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 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 services obtained from a specialist and a 20% 
coinsurance for Medicare Part B prescription drugs. You can find this information on pages 4-37 to 4-40 and 4-
58 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 active diagnoses are intended to code diseases that have a direct relationship to the residents 
current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or 
risk of death. One of the important functions of the Minimum Data Set (MDS) assessment is to generate an 
updated, accurate picture of the residents current health status. You can find this rule in the Centers for 
Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 
3. 
 
The rules state that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This 
involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new 
Patient-Driven Payment Model (PDPM), which is effective for services provided on or after 10/1/2019, the 
HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under 
the revised model. The first position represents the Physical and Occupational Therapy case-mix group. The 
second position represents the Speech-Language Pathology (SLP) case-mix group. The third character 
represents the nursing case-mix group. The fourth character represents the Non-Therapy Ancillary (NTA) case-
mix group. The fifth character represents the assessment indicator code. You can find this information in the 
Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, Medicare Claims Processing 
Manual, Chapter 6, Sections 10, 30, and 120. 
 
 
 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.