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 repeat polysomnography (PSG) or home sleep tests (HST) for diagnosing sleep apnea 
requires documentation justifying the medical necessity for the repeated test. Repeat PSG may be indicated: 
 if the first study is technically inadequate due to equipment failure; 
 if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; 
 if the results were inconclusive or ambiguous; or 
 if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed. 
Follow-up PSG or HST is not routinely indicated for patients treated with CPAP, whose symptoms continue to 
be resolved with continuous positive airway pressure (CPAP) treatment. Follow-up PSG may be indicated; 
however, under the following circumstances: 
 After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing 
disorders to ascertain whether CPAP is still needed at the previously titrated pressure; 
 After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are 
again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; 
or 
 When clinical response is insufficient or when symptoms return despite a good initial response to treatment 
with CPAP. 
You can find this information in the Local Coverage Determination (LCD) for Polysomnography (L36593). 
 
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 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 $90 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page(s) 95 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 status code T means that there are relative value units (RVUs) and payment amounts for these 
services, but they are only paid if there are no other services payable under the physician fee schedule billed on 
the same date by the same provider. If any other services payable under the physician fee schedule are billed on 
the same date by the same provider, these services are bundled into the physician services for which payment is 
made. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that laboratory providers who bill Molecular Diagnostic Tests (MDT) services must register test 
services on the DEX Diagnostics Exchange. Under Covered Tests subheading deleted the verbiage, To 
obtain a unique identifier for a test and, to submit information for a technical assessment go to DEX 
Diagnostics Exchange https://app.dexzcodes.com/login. You can find this information in Medicare's Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L35025). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of 
the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.2(B). The 
rules also say not withstanding any other provision of this title, no payment may be made under part A or part 
B for any expenses incurred for items or services (1)(A) which, except for items and services described in a 
succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or 
to improve the functioning of a malformed body member.  
 
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 pharmacogenomics testing (PGx) testing is considered reasonable and necessary in limited 
circumstances as described below as an adjunctive personalized medical decision-making tool once a treating 
clinician has narrowed treatment possibilities to specific medications under consideration for use, or is already 
using a specified medication, based on other clinical considerations including the patients diagnosis, the 
patients other medical conditions, other medications, professional judgment, clinical science and basic science 
pertinent to the drug, and the patients preferences and values. 
PGx tests must demonstrate analytical validity, clinical validity, and clinical utility to be considered reasonable 
and necessary for coverage. This is demonstrated through a required technical assessment of the test. PGx tests 
are considered germline tests and must adhere to other relevant germline testing policies published by this 
contractor. You can find this rule in Local Coverage Determination (LCD) MolDX: Pharmacogenomics 
Testing L38394. 
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 $110 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page(s) 64 to 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 prosthetic coverage is extended only if there is sufficient clinical documentation of 
functional need for the technologic or design feature of a given type of knee. This information must be retained 
in the treating practitioner's or prosthetist's files. You can find this in the Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787). 
 
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 $100 copayment for in-network outpatient hospital services. You can 
find this information on page(s) 63 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 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).  
 
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 there is a $400 deductible which applies to certain items and services. The Plan 
deductible applies to outpatient surgery. You can find this information on pages 56-57 of the Plan's 2022 
Evidence of Coverage (EOC).   
 
The Plan contract also says that enrollees must pay a $400 copayment after meeting the deductible for in-
network outpatient surgery provided at an ambulatory surgical center. You can find this information on page 83 
of the Plans 2022 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 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. The Plan contract says that the POS benefit only applies to 
covered routine dental services. 
 
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. Although the Plan has a Point-of-Service (POS) option to cover 
certain out-of-network services, this benefit only applies to covered routine dental services. You can find this 
information on pages 27-28 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 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 under Group 2 Paragraph - These codes are non-covered: 0202U. You can find this rule in 
Local Coverage Article Billing and Coding Billing and Coding: Respiratory Pathogen Panel Testing A58741. 
 
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 following indications are covered nationally unless otherwise indicated: 
 
    1. Computer analysis of electrocardiograms (EKGs) when furnished in a setting and under the circumstances 
required for coverage of other EKG services. 
    2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
    3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed as 
a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the 
time the service is performed or immediately thereafter. 
   4. Home EKG services with documentation of medical necessity. 
   5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to 
the physicians service in interpreting the results of such transmissions, including charges for rental of the 
equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME 
separately. Covered uses are to: 
       a. Detect, characterize, and document symptomatic transient arrhythmias; 
       b. Initiate, revise, or discontinue arrhythmic drug therapy; or, 
       c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 
24-hour coverage is provided, see C.5. below). 
 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. 
 
You can find this information in National Coverage Determination (NCD): Electrocardiographic Services 
(20.15). 
 
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 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 if contractors have evidence (e.g., medical review) that unit of service (UOS) in excess of the 
medical unlikely edit (MUE) value were actually provided, were correctly coded and were medically necessary, 
the contractor may bypass the MUE for a Healthcare Common Procedure Coding System (HCPCS) code with 
an MUE Adjudication Indicator (MAI) of 3 during claim processing, reopening, or redetermination, or in 
response to effectuation instructions from a reconsideration or higher-level appeal. You can find this 
information in Medicare's National Correct Coding Initiative (NCCI) Policy Manual, Chapter I General Correct 
Coding Policies, Section V. Medically Unlikely Edits (MUEs). 
 
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 psychotherapy is defined as the treatment for mental illness and behavioral disturbances in 
which the clinician establishes a professional contract with the patient and through definitive therapeutic 
communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of 
behavior and encourage personality growth and development or support current evaluation of functioning. 
Psychotherapy services include ongoing assessment and adjustment of psychotherapeutic interventions and 
may include involvement of family member(s) or others in the treatment process. Although maintenance per se 
is not covered, helping a patient maintain his/her highest level of functioning, such as a patient with borderline 
personality disorder, may be covered on a case-by-case basis. These case-by-case considerations must be 
supported by the evaluation and a plan with clearly identified goal(s). You can find this information in the 
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 unique Test Identifier Requirement: "Because the available language in the current Health 
Insurance Portability and Accountability Act (HIPAA) compliant code sets used to describe the pathology and 
laboratory categories and the tests included in those categories are not specific to the actual test results 
provided, all MDT services must include an identifier as additional claim documentation. Test providers must 
receive an identifier specific to the applicable test and submit the test assigned identifier with the claim for 
reimbursement. The assigned identifier will provide a crosswalk between the test's associated detail 
information on file and the submitted claim detail line(s) required to adjudicate each test's claim. You can find 
this information in Medicare's Local Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests 
(MDT) (L35025). 
 
The rules say status code T means that there are relative value units (RVUs) and payment amounts for these 
services, but they are only paid if there are no other services payable under the physician fee schedule billed on 
the same date by the same provider. If any other services payable under the physician fee schedule are billed on 
the same date by the same provider, these services are bundled into the physician services for which payment is 
made. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30.2.2. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator B means that payment for covered services is 
always bundled into payment for other services not specified. There will be no payment amounts for these codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident. You can find this information in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 23, Section 30.2.2. 
 
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 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 $30 copayment for in and out-of-network Medicare-covered 
radiological diagnostic services, including ultrasounds. You can find this information on page(s) 108 of the 
Plan's 2023 Evidence of Coverage.