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 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 some psychiatry services may be reported with evaluation and management (E/M) services 
or other services when performed. An E/M code may be used to report evaluation and management services 
alone (no other service reported that day) or used to report an E/M service with psychotherapy. An E/M service 
is based on the physicians work and includes services medically necessary to evaluate and treat the patient. 
You can find this rule in Local Coverage Determination (LCD) Psychiatry and Psychology Services L34616. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that CMS is creating additional flexibilities to allow licensed independent freestanding 
emergency departments (EDs) to participate in Medicare and Medicaid to help address the urgent need to 
increase hospital capacity to provide care to patients. The following ways to participate include: 
Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 
emergency waiver. Participating in Medicaid under the clinic benefit if permitted by the State, or 
Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services. You can find this 
information in The Centers for Medicare and Medicaid Services (CMS) Guidance for Licensed Independent 
Freestanding Emergency Departments (EDs) to Participate in Medicare and Medicaid during the COVID-19 
Public Health Emergency. 
 
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 home blood pressure monitors (A4660) and home blood pressure cuffs (A4663) are 
considered home dialysis supplies. These items are only covered for patients on home dialysis and they are not 
payable to Durable Medical Equipment suppliers. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Transmittal 
250, Change Request 11021, Attachment B, dated November 14, 2018. 
 
The rules also say that ambulatory blood pressure monitoring (ABPM) may be covered in some instances. This 
service involves the use of a non-invasive device which is used to measure blood pressure in 24-hour cycles. 
These 24-hour measurements are stored in the device and are later interpreted by the physician. ABPM is only 
covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is 
defined as: 
 
1. Office blood pressure greater than 140/90 mm Hg on at least three separate clinic/office visits with two 
separate measurements made at each visit; 
2. At least two documented blood pressure measurements taken outside the office which are less than 140/90 
mm Hg; and 
3. No evidence of end-organ damage. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 10-03, National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring 
(20.19). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the A/B Medicare Administrative Contractor (MAC) (B) must pay for screening 
colonoscopies (code G0105) when performed by a doctor of medicine or osteopathy at a frequency of once 
every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have 
passed following the month in which the last covered G0105 screening colonoscopy was performed). Refer to 
Section 280.2.3 for the criteria to use in determining whether or not an individual is at high risk for developing 
colorectal cancer. You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 
280.2.2. 
 
The rules say that an individual at high risk for developing colorectal cancer has one or more of the following: 
A close relative (sibling, parent, or child) who has had colorectal cancer or an 
adenomatous polyp; 
A family history of familial adenomatous polyposis; 
A family history of hereditary nonpolyposis colorectal cancer; 
A personal history of colorectal cancer; 
A personal history of adenomatous polyps; 
Inflammatory bowel disease, including Crohns Disease, and ulcerative colitis. 
 
You can find this information in the Medicare Benefit Policy Manual, Chapter 15, Section 280.2.3. 
 
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 Prolia, for all patients, is allowed under the following circumstances: 
 
   - the oral health of the patient was discussed 
   - the patient was instructed to take 1,000 mg of calcium and at least 400 IU of vitamin D per day  
 
You can find this information in Local Coverage Determination (LCD): Bisphosphonates (Intravenous [IV]) 
and Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications (L33270). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
The rules say subluxation may be shown by x-ray or physical exam. 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 240.1.2. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 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 physicians /practitioners who furnish services to a hospital outpatient, including in a hospital 
outpatient department (including in a provider-based department of that hospital) or under arrangement to a 
hospital shall, at a minimum, report the off campus-outpatient hospital POS code 19 or on campus-outpatient 
hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual Chapter 26, Section 10.5. 
 
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).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Pneumatic Compression Device (PCD) that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare Durable Medical Equipment 
(DME) benefit. A PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 will be denied 
as not reasonable and necessary. You can find this information in the Local Coverage Article: Pneumatic 
Compression Devices - Policy Article (A52488) and in the Local Coverage Determination (LCD): Pneumatic 
Compression Devices (L33829). 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is a hospital or a skilled nursing 
facility (SNF). 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(D). 
 
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 all beneficiaries receiving home health services in 2021 whose services will continue in 
2022, the home health agency (HHA) shall submit a Notice of Admission (NOA) with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. For example, if 
a period of care begins in 2021 and ends on January 10, 2022, the HHA submits an NOA with an admission 
date of January 11, 2022, and then submits a claim when the 30-day period of care is over. The HHA should 
submit the January 11, 2022, admission date on all subsequent claims until the beneficiary is discharged and 
another NOA is required. This is to ensure the claim is matched to the correct NOA and the correct receipt date 
is used for payment. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 
10.1.10.3. 
 
The rules say the following data elements are required to submit an NOA under Home Health Prospective 
Payment System (HH PPS): 
 
--The HHA reports the date of the first visit provided in the admission as the From date. The Through date on 
the NOA must always match the From date. 
--The Admission date on the NOA must always match the From date. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.1. 
 
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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, 
  3. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results, 
  4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and, 
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the term PAP (positive airway pressure) device will refer to both a single-level continuous 
positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) 
when it is used in the treatment of obstructive sleep apnea. 
 
    An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A  C are met: 
 
        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. 
 
        The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2): 
 
            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, 
 
            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: 
 
                Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
                Hypertension, ischemic heart disease, or history of stroke. 
 
        The beneficiary and/or their caregiver has received instruction from the supplier of the device in the 
proper use and care of the equipment. 
 
If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not 
reasonable and necessary. 
 
    An E0470 device is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to 
criterion D: 
 
        An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility 
or in a home setting. 
 You can find these rules in the Local Coverage Determination (LCD) Positive Airway Pressure (PAP) Devices 
for the Treatment of Obstructive Sleep Apnea L33718. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information 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 wound cleansers (A6260) or irrigating solutions are examples of wound care items which 
are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a 
dressing. You can find this information in the Local Coverage Article: Surgical Dressings - Policy Article 
(A54563). 
 
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 contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
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 160. 
 
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 to see your Plan's Dental Plan Information Guide for details on covered services. You can find this 
information on pages 44 and 45 of the Plan's 2022 Evidence of Coverage. 
 
The Plan contract says your dental benefit includes incisional biopsy of oral tissue (D7286), and you are 
responsible for a $75 copayment. You can find this information on page 17 of the Plan's 2022 Dental Care 
Plan.