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 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 payment is 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, Internet-Only Manual, Publication 100-04, 
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.
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 wounds and ulcers, once placed on a NPWT pump and supplies, in order for coverage to 
continue, a licensed medical professional must do the following: 
 
1. On a regular basis, 
 
a. Directly assess the wound(s) being treated with the NPWT pump, and 
b. Supervise or directly perform the NPWT dressing changes, and 
 
2. On at least a monthly basis, document changes in the ulcers dimensions and characteristics. 
 
You can find this rule in the Local Coverage Determination (LCD) - Negative Pressure Wound Therapy Pumps 
(L33821). 
 
The rules say for wounds and ulcers, a NPWT pump and supplies will be denied as not reasonable and 
necessary when in the judgment of the treating practitioner, adequate wound healing has occurred to the degree 
that NPWT may be discontinued, or any measurable degree of wound healing has failed to occur over the prior 
month. Wound healing is defined as improvement occurring in either surface area (length times width) or depth 
of the wound. You can find this rule in the Local Coverage Determination (LCD) - Negative Pressure Wound 
Therapy Pumps (L33821). 
 
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 Medicare will consider invasive procedures as reasonable and necessary when 
documentation in the medical record includes a history, physical examination, clinical classification, and a 
venous duplex scan documenting reflux greater than 500 msec. This information is found in Local Coverage 
Determination (LCD): Treatment of Varicose Veins of the Lower Extremities (L39121). 
 
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 only certain diagnosis codes are covered for urine culture testing. You can find this rule in 
the National Coverage Determination (NCD) for Urine Culture, Bacterial (190.12). 
 
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 a negative pressure wound therapy (NPWT) pump (E2402) and supplies are covered when 
the beneficiary has a chronic Stage 3 or 4 pressure ulcer (see Appendices Section), neuropathic (for example, 
diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 30 days) ulcer of 
mixed etiology. A complete wound therapy program described by criterion 1 and criteria 2, 3, or 4, as 
applicable depending on the type of wound, must have been tried or considered and ruled out prior to 
application of NPWT. 
 
1. For all ulcers or wounds, the following components of a wound therapy program must include a minimum of 
all of the following general measures, which should either be addressed, applied, or considered and ruled out 
prior to application of NPWT: 
 
a. Documentation in the beneficiary's medical record of evaluation, care, and wound measurements by a 
licensed medical professional, and 
b. Application of dressings to maintain a moist wound environment, and 
c. Debridement of necrotic tissue if present, and 
d. Evaluation of and provision for adequate nutritional status 
 
2. For Stage 3 of 4 pressure ulcers: 
 
a. The beneficiary has been appropriately turned and positioned, and 
b. The beneficiary has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis, 
and 
c. The beneficiarys moisture and incontinence have been appropriately managed 
 
3. For neuropathic (for example, diabetic) ulcers: 
 
a. The beneficiary has been on a comprehensive diabetic management program, and 
b. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities 
 4. For venous insufficiency ulcers 
 
a. Compression bandages and/or garments have been consistently applied, and 
b. Leg elevation and ambulation have been encouraged 
 
You can find this rule in the Local Coverage Determination (LCD) - Negative Pressure Wound Therapy Pumps 
(L33821) - Effective May 1, 2021. 
 
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 dialysis sessions that have been furnished 3 times (3X) per week, each line should be 
90999 without any modifiers appended. That is, when the hemodialysis-prescription is 3 times (3X) per week 
and each session is furnished, all of these sessions be billed as 90999 (no modifier appended) and they will be 
paid as routine conventional dialysis up to 13/14 per month. You can find this rule at Local Coverage Article 
(LCA) A55672: Billing and Coding: Frequency of Hemodialysis (eff. 10/1/22). 
 
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 thermal radiofrequency ablation (RFA) procedures are considered medically 
reasonable and necessary after the patient has had at least two (2) medically reasonable and necessary 
diagnostic medial branch blocks (MMBs), with each one providing a consistent minimum of 80% sustained 
relief of primary (index) pain (with the duration of relief being consistent with the agent used). You can find 
this rule in Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L35936). 
 
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 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 12 one-way trips each year. You can find this information on pages 86-87 of the Plans 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 patient status code 06 should be reported in all cases where the HHA is aware that the period 
of care will be paid a partial period payment adjustment. These are cases in which the agency is aware that the 
beneficiary has transferred to another HHA within the 30-day period, or the agency is aware that the 
beneficiary was discharged with the goals of the  
original plan of care met and has been readmitted within the period. Situations may occur in which the HHA is 
unaware at the time of billing the discharge that these circumstances exist. In these situations, Medicare claims 
processing systems will adjust the discharge claim automatically to reflect the partial period payment 
adjustment, changing the patient status code on the paid claims record to 06. You can find this rule in the 
Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing Manual, Chapter 10, 
Section 40.2. 
 
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 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 Ambulatory Electrocardiograph (AECG) monitoring, when performed with a device that has 
FDA clearance, will be considered medically reasonable and necessary in the following situations: 
1. A standard 12-lead electrocardiograph (ECG), complete cardiac history and cardiac exam has not 
satisfactorily explained the patient's cardiac complaints and AECG testing will provide diagnostic 
information that will assist in developing a treatment plan or changing a treatment plan for patients that 
are at risk for cardiac arrythmias. 
2. For patients experiencing unexplained syncope, near syncope, episodic dizziness, chest pain, 
palpitations, and/or shortness of breath. 
3. To assess documented or suspected bradycardia. 
4. For patients experiencing nocturnal arrhythmias. 
5. To assess the average heart rate and adequacy of rate control in a patient with atrial fibrillation. 
6. To aid in the regulation of anti-arrhythmic drug dosage. 
7. To assess the effectiveness of arrhythmia therapy (e.g., post ablation). 
8. To evaluate prognosis following acute coronary syndrome. 
9. Pre/Post implantable cardiac defibrillator reprogramming. 
10. To assess for silent myocardial ischemia in a patient with known or suspected coronary heart disease. 
11. To assess for asymptomatic ventricular premature beats or non-sustained ventricular tachycardia in 
patients with hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long QT 
syndrome, dilated or restrictive cardiomyopathy, congenital heart disease, or Brugada syndrome. 12. To evaluate for occult atrial fibrillation (A-Fib) as a potential cause of cardio-embolism in patients with 
cryptogenic stroke. 
You can find this information in the Local Coverage Determination (LCD): Ambulatory Electrocardiograph 
(AECG) Monitoring (L39490). 
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) - Effective April 8, 2021. 
 
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 sequela is the residual effect (condition produced) after the acute phase of an illness or 
injury has terminated. There is no time limit on when a sequela code can be used. Coding of sequela generally 
requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. 
The sequela code is sequenced second. You can find this information in the International Classification of 
Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting 
FY2022. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay 20% coinsurance for services to treat kidney disease. You can find this 
information on page(s) 60-61 of the Plan's 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 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 Molecular Diagnostic Services Program (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. MolDX will reimburse approved tests covered for dates of 
service consistent with the effective date of the coverage determination. You can find this rule in Local 
Coverage Determination (LCD) MolDX: Molecular Diagnostic Tests (MDT) L36807. 
 
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: 
 
Indications and Limitations of Coverage 
 
A.      Nationally Covered Conditions 
 Payment may be made only where sterilization is a necessary part of the treatment of an illness or 
injury, e.g., removal of a uterus because of a tumor, removal of diseased ovaries. 
 Sterilization of a mentally challenged beneficiary is covered if it is a necessary part of the treatment of 
an illness or injury (bilateral oophorectomy or bilateral orchidectomy in a case of cancer of the 
prostate). The Medicare Administrative Contractor denies claims when the pathological evidence of the 
necessity to perform any such procedures to treat an illness or injury is absent; and 
 Monitor such surgeries closely and obtain the information needed to determine whether in fact the 
surgery was performed as a means of treating an illness or injury or only to achieve sterilization. 
B.       Nationally Non-Covered Conditions 
 Elective hysterectomy, tubal ligation, and vasectomy, if the primary indication for these procedures is 
sterilization; 
 A sterilization that is performed because a physician believes another pregnancy would endanger the 
overall general health of the woman is not considered to be reasonable and necessary for the diagnosis 
or treatment of illness or injury within the meaning of 1862(a)(1) of the Social Security Act. The same 
conclusion would apply where the sterilization is performed only as a measure to prevent the possible 
development of, or effect on, a mental condition should the individual become pregnant; and 
sterilization of a mentally retarded person where the purpose is to prevent conception, rather than the 
treatment of an illness or injury. 
You can find this rule at the Medicare National Coverage Determination (NCD) 230.3: Sterilization. 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that elective hysterectomy, tubal ligation, or vasectomy, if the primary indication for these 
procedures is sterilization. Reversal of sterilization procedures, penile vacuum erection devices, or non- 
prescription contraceptive supplies are not covered under any condition. You can find this information on page 
4-84 of the Plan's 2022 Evidence of Coverage.