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 the global surgery package of procedures with a global period of 10 or 90 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the surgery 
because of complications which do not require additional trips to the operating room, follow-up visits during 
the postoperative period of the surgery that are related to recovery from the surgery, among other related 
services. In order to report an unrelated evaluation and management (EM) service by same physician during a 
postoperative period, modifier -24 must be used. Services submitted with the -24 modifier must be sufficiently 
documented to establish that the visit was unrelated to the surgery. Not included in the global surgery payment 
are clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment 
for complications. These services should be billed with modifier -79. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Section 40.1. 
 
The rules say that Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be 
used on claims for evaluation and management (E/M) services, and only when these services are provided by 
the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another 
procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global 
fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that 
is above and beyond the usual pre- and post-operative work of the procedure. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claim 
Processing Manual Chapter 12, Section 30.6.6. 
 
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 will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 certain dental services as a supplemental (extra) benefit. This benefit includes 
preventive and comprehensive dental services along with specific dental codes that are listed on the dental 
benefit chart. Crowns and core buildup are covered by the Plan's dental benefits. You can find this information 
on pages 90 to 102 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 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 $40 copayment for physician/practitioner services, including doctors 
office visits. You can find this information on page(s) 72 of the Plan's 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 a Group 3 power wheelchair (PWC) with multiple power options (such as code K0861) is 
covered if: 
     A. All of the coverage criteria for a PWC are met; and 
     B. The beneficiarys mobility limitation is due to a neurological condition, myopathy, or congenital 
deformity; and 
     C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a physical therapist (PT) or occupational therapist (OT), or practitioner who has specific 
training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner 
may have no financial relationship with the supplier; and 
     D. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA) certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary. 
     E. Criterion 1 or 2 is met; and 
          1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair 
Options and Accessories policy) and the system is being used on the wheelchair. 
          2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
 
If the PWC base is not covered, then related accessories will be denied. You can find this information in the 
Local Coverage Determination (LCD) for Power Mobility Devices (L33789). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the Centers for Medicare & Medicaid Services (CMS) has determined that percutaneous 
image-guided lumbar decompression (PILD) will be covered by Medicare when provided in a clinical study 
under section 1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development 
(CED) for beneficiaries with lumbar spinal stenosis (LSS) who are enrolled in an approved clinical study that 
meets the criteria in section I or II below: 
I. Effective for services performed on or after January 9, 2014, PILD will be covered by Medicare 
through CED for beneficiaries with LSS who are enrolled in an approved clinical study meeting 
selection criteria. CMS has a particular interest in improved beneficiary function and quality of life, 
specific characteristics that identify patients who may benefit from the procedure, and the duration 
of benefit. A clinical study seeking Medicare payment for PILD for LSS must address one or more 
aspects of the following questions in a prospective, randomized, controlled design using current 
validated and reliable measurement instruments and clinically appropriate comparator treatments, 
including appropriate medical or surgical interventions or a sham controlled arm, for patients 
randomized to the non-PILD group. 
II. Effective for services performed on or after December 7, 2016, CMS will cover through a 
prospective, longitudinal study PILD procedures using an FDA-approved/cleared device that 
completed a CMS-approved randomized control trial (RCT) that met the criteria listed in section I 
above. 
 
You can find these rules in National Coverage Determination (NCD) Percutaneous Image-Guided Lumbar 
Decompression for Lumbar Spinal Stenosis (150.13). 
 
The rules state that NCT03072927 is currently recruiting participants. The eligibility criteria for participation in 
study NCT03072927 are: 
- Inclusion Criteria 
~ Medicare beneficiaries receiving MILD or interspinous process decompression 
~ Diagnosis of lumbar spinal stenosis (LSS) with neurogenic claudication (NC) 
- Exclusion Criteria ~ Patients that have received a laminectomy, laminotomy, fusion, interspinous process 
decompression, or MILD in the lumbar region during the 12 months prior to the index date. 
 
You can find these rules in the National Institutes of Health (NIH) National Library of Medicine, National 
Center for Biotechnology Information Clinical Trials Study Record for NCT03072927 MILD Percutaneous 
Image-Guided Lumbar Decompression: A Medicare Claims Study (updated as of October 17, 2023) which can 
be accessed at https://clinicaltrials.gov/study/NCT03072927. 
 
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 Plan 
contract says that they have a link will take you to a list of Part B Drugs that may be subject to Step Therapy. 
You can find this information in Chapter 4 on page 67 of the Plan's 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 state that no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each 
provider and supplier enroll with the appropriate Medicare fee-for-service contractor. Chapter 15 - Medicare 
Enrollment 
 
A provider is defined and generally means a hospital, critical access hospital, skilled nursing facility, 
comprehensive outpatient rehabilitation facility, home health agency or hospice, that has in effect an agreement 
to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar 
agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental 
health center that has in effect a similar agreement but only to furnish partial hospitalization services. You can 
find this rule at 42 CFR 400.202. 
 
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 a $35 copayment for in-network specialist visits. You can find this 
information on page(s) 114 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 state that home health agencies must submit home health Prospective Payment System (PPS) claims 
with a type of bill with the 4th digit of 9. These claims may be adjusted with code 7 or cancelled with code 
8. A/B MACs (HHH) do not accept late charge bills, submitted with code 5, on home health PPS claims. 
To add services within the period of a paid home health claim, the home health agency must submit an 
adjustment. This rule is found in the Medicare Claims Processing Manual Chapter 10 - Home Health Agency 
Billing, 40.2 - Home Health PPS Claims. 
 
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 the SNF Prospective Payment System (PPS) establishes a Medicare-required PPS 
assessment schedule. Each required assessment supports reimbursement for a range of days of a Part A covered 
stay. The schedule includes assessments performed around Days 5, 14, 30, 60, and 90 of the stay. Additional 
unscheduled assessments are required under specific circumstances.  You can find this rule at Centers for 
Medicare and Medicaid Services, MedLearn Matters bulleting entitled "Medicare-Required SNF PPS 
Assessments." 
 
The rules say that if no assessment occurs, the SNF stay is paid based on the default ZZZZZ PDPM Score. You 
can find this rule at  Centers for Medicare and Medicaid Services, MedLearn Matters bulleting entitled "Skilled 
Nursing Facility Billing Reference." 
 
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 a $35 copayment for Medicare-covered physical therapy in-person visits. 
You can find this information on page 58 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $55 copayment for out-of-network Medicare-covered physical 
therapy visits. You can find this information on page 58 of the Plans 2022 Evidence of Coverage (EOC). 
 
The Plan contract says that enrollees must pay a $50 copayment for out-of-network Medicare-covered Physical 
Therapy in-person visits. You can find this information on pages 50 to 51 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 to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
 
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 where electric nerve stimulation is employed to treat motor function disorders, no 
reimbursement may be made for the stimulator or for the services related to its implantation since this treatment 
cannot be considered reasonable and necessary. You can find this rule in the National Coverage Determination 
(NCD) for Treatment of Motor Function Disorders with Electric Nerve Stimulation (160.2). 
 
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 therapeutic embolization is covered when done for hemorrhage, and for other conditions 
amenable to treatment by the procedure, when reasonable and necessary for the individual patient. Renal 
embolization for the treatment of renal adenocarcinoma continues to be covered, effective December 15, 1978, 
as one type of therapeutic embolization, to: 
 
Reduce tumor vascularity preoperatively; 
Reduce tumor bulk in inoperable cases; or 
Palliate specific symptoms. 
 
You can find this information in the National Coverage Determination (NCD) Therapeutic Embolization 20.28. 
 
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.