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 a Medicare plan may restrict enrollees to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the plan must 
arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-
network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees 
medical needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
The rules say that plans may specify the networks of providers from whom enrollees may obtain services. The 
rules say plans may require prior authorization for most in-network services if the health plan ensures that all 
covered services are available and accessible under the plan. The plan must arrange for specialty care outside of 
the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical 
needs. Plans offering coordinated care plans must ensure continuity of care and integration of services through 
arrangements with contracted providers. This includes services available through contracting or non-
contracting providers in the area serviced by the health plan including nursing home and community-based 
services. You can find this rule at 42 CFR Section 422.112. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 25 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 payment can be made under the fee schedule for anesthesia services associated with 
multiple surgical procedures or multiple bilateral procedures. Payment is determined based on the base unit of 
the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of 
the multiple procedures. Physicians report the appropriate modifier to denote whether the service meets the 
requirements for payment at the personally performed rate, medically directed rate, or medically supervised 
rate. There is a list of recognized modifiers for anesthesia services. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 12, Section 50. 
 
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 expanded panel testing is only indicated when targeted panel testing is not appropriate (i.e., 
will not provide sufficient information for the appropriate clinical management of the patient). The test panel is 
a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel 
cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple 
individual pathogens and/or targets. You can find this rule in the Local Coverage Determination and Article for 
Molecular Diagnostics (MolDX): Molecular Syndromic Panels for Infectious Disease Pathogen Identification 
Testing, L38988 and A58710. 
 
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 a dental 
maximum of $600 for preventive and comprehensive dental services in the year of 2021. This benefit also 
includes a dental maximum of $675 for preventive and comprehensive dental services in the year of 2022. You 
can find this information on pages 67 to 69 of the Plan's 2021 Evidence of Coverage (EOC) and pages 77 to 79 
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. 
 
A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 
3): 
 
    1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the ICD-10 
code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over 
the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program 
including each of the following: 
        Use of an appropriate group 1 support surface, and 
        Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
        Appropriate turning and positioning, and 
        Appropriate wound care, and 
        Appropriate management of moisture/incontinence, and 
        Nutritional assessment and intervention consistent with the overall plan of care 
   2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis (refer to the ICD-
10 code list section in the LCD-related Policy Article for applicable diagnoses), 
    3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the 
past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing 
facility within the past 30 days 
 
If the beneficiary is on a group 2 surface, there should be a care plan established by the treating practitioner or 
home care nurse which includes the above elements. The support surface provided for the beneficiary should be 
one in which the beneficiary does not "bottom out" (see Appendices section). 
 
When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited 
to 60 days from the date of surgery. 
 
When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not 
reasonable and necessary.  
You can find this information in the Local Coverage Determination (LCD) Pressure Reducing Support 
Surfaces - Group 2 L33642. 
 
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 home health prospective payment system (HH PPS) claims must report a 0023 revenue code 
line which contains a Health Insurance Prospective Payment System (HIPPS) code. HHAs enter only one 0023 
revenue code per claim in all cases. Claims must also report all services provided to the beneficiary within the 
period of care. All services must be billed on one claim for the entire period. Each service must be reported in 
line-item detail. Each service visit (revenue codes 042x, 043x, 044x, 055x, 056x and 057x) must be reported as 
a separate line. To report home health visits, the HHA reports physical therapy codes with revenue code 042x. 
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 40.2. 
 
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 Palmetto GBA is concerned that there are no randomized controlled trials (RCTs) that 
specifically evaluated adults = 61 years, few large scale trials on stand-alone LSG and few, if any, long-term 
trials. Palmetto GBA medical directors have also discussed the surgery with subject matter experts in our 
jurisdiction. Given the strengths and limitations of the evidence, Palmetto GBA will cover laparoscopic sleeve 
gastrectomy only when ALL of the following criteria are met: 
 
    Patient has a BMI = 35.0 kg/m2 (Class II or Class III obesity) 
    Patient has at least 1 co-morbidity related to obesity, and, 
    Active participation within the last 12 months prior to bariatric surgery in a weight-management program 
that is supervised by a physician or other health care professionals. The weight-management program must 
include monthly documentation of ALL of the following components: 
        weight 
        current dietary regimen 
        physical activity (e.g., exercise program) 
 
You can find this information in the Local Coverage Determination (LCD) Laparoscopic Sleeve Gastrectomy 
for Severe Obesity L34576. 
 
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 per visit for emergency care. You can find this 
information on page 72 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $250 copayment per day for days 1-7 per admission for 
inpatient hospital stay. You can find this information on pages 83 to 84 of the Plans 2022 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules state that an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit 
Policy Manual, Chapter 15, Section 80.6.1. 
 
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 the type of bill is a data element that is required to submit a claim under home health PPS. 
This 4-digit alphanumeric code gives two pieces of information. The first three digits indicate the base type of 
bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill 
accepted for home health PPS claims are 032x (home health services under a plan of treatment). The rules say 
that home health agencies (HHA) must submit claims 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 HH PPS claims. To add services within the period of a paid HH claim, the HHA must submit an 
adjustment. You can find this rule in the 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 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 find this information at the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program 
Integrity Manual, Chapter 3, Section 3.3.2.1 
 
The rules also say that no transportation charge is payable unless the portable x-ray equipment used was 
actually transported to the location where the x-ray was taken. For example, carriers do not allow a 
transportation charge when the x-ray equipment is stored in a nursing home for use as needed. You can find 
this information at the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 15, Section 90.3. 
 
The rules also say that carriers must pay a set-up component for each radiologic procedure (other than retakes 
of the same procedure) during both single patient and multiple patient trips under Level II Healthcare Common 
Procedure Coding System (HCPCS) code Q0092. You can find this information at the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 15, Section 90.4. 
 
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 transportation, including transportation by ambulance, to and from another hospital or 
freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where 
the patient is an inpatient. You can find this rule in the CMS Medicare Claims Processing Manual 100-04, 
Chapter 3, Section 10.4: A. 
 
The rules also say that hospital bundling rules exclude payment to independent suppliers of ambulance services 
for beneficiaries in a hospital inpatient stay. The Common Working File (CWF) performs reject edits to 
incoming claims from independent suppliers of ambulance services. The CWF searches paid claim history and 
compares the line-item service date on an ambulance claim to the admission and discharge dates on a hospital 
inpatient stay. The CWF rejects the line item when the ambulance line-item service date falls within the 
admission and discharge dates on a hospital inpatient claim. Based on CWF rejects, the A/B MAC (B) must 
deny line items for ambulance services billed by independent suppliers that should be bundled to the hospital.  
Upon receipt of a hospital inpatient claim, CWF searches paid claim history and compares the period between  
the hospital inpatient admission and discharge dates to the line-item service date on an ambulance claim billed  
by an independent supplier. The CWF shall generate an unsolicited response when the line-item service date  
falls within the admission and discharge dates of the hospital inpatient claim. You can find this rule in the CMS 
Medicare Claims Processing Manual 100-04, Chapter 3, 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 percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for the following indications: 
I. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
1. Both PVP and PVA will be considered reasonable and necessary when all of the following 
criteria are met: 
A. Acute (<6 wks) or subacute (6-12 wks) osteoporotic vertebral compression fracture 
(VCF), based on symptom onset, and documented by advanced imaging demonstrating 
bone marrow edema on MRI or bone-scan/SPECT/CT uptake and 
B. The beneficiary is symptomatic and is hospitalized with severe pain or is non-
hospitalized with moderate to severe pain despite optimal non-surgical management 
(NSM) with one of the following: 
i. Worsening Pain or 
ii. Stable to improved pain when 2 or more of the following are present: 
- Progression of vertebral body height loss 
- > 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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 the Physician Fee Schedule Status Indicator X means that these codes represent an item or 
service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No 
payment amounts are shown for these codes, and no payment may be made under the physician fee schedule. 
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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.