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 a written order/prescription is a written communication from a treating practitioner that 
documents the need for a beneficiary to be provided an item of Durable Medical Equipment, Prosthetics, 
Orthotics, and Supplies (DMEPOS). All DMEPOS items require a written order/prescription from the treating 
practitioner for Medicare payment as a condition of payment. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, 
Chapter 5, Section 5.2. 
 
The rules say that for any DMEPOS item to be covered by Medicare, the patients medical record must contain 
sufficient documentation of the patients medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement (if applicable). The information should 
include the patients diagnosis and other pertinent information including, but not limited to, duration of the 
patients condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Pub 100-08, Medicare Program 
Integrity Manual, Chapter 5, Section 5.9. 
 
The rules say that a spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following 
indications: 
 
-To reduce pain by restricting mobility of the trunk; or 
 
-To facilitate healing following an injury to the spine or related soft tissues; or 
 
-To facilitate healing following a surgical procedure on the spine or related soft tissue; or 
 
-To otherwise support weak spinal muscles and/or a deformed spine. 
 
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically 
necessary. You can find this rule in Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO 
(L33790). 
 
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 in order to qualify as a valid echocardiographic service, the study must be done for an 
accepted clinical indication by a properly trained examiner and must include a permanent record of the 
findings, data sufficient to support the conclusions and an appropriate interpretation and written report. Such a 
study would meet the standards required for a complete echocardiographic examination, regardless of the size 
or portability of the instrument used to perform the study. You can find this information in Local Coverage 
Determination (LCD): Transthoracic Echocardiography (TTE) (L33577). 
 
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, as a general policy, the POS code assigned by the physician/practitioner for the PC of a 
diagnostic service shall be the setting in which the beneficiary received the TC service. This is in the Claims 
Processing Manual, Chapter 13, 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.
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 Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
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. 
 
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 as a member of the plan, the most you will have to pay out-of-pocket for in-network 
covered Part A and Part B services in 2022 is $6,700. The amounts you pay for copayments and coinsurance 
for in-network covered services count toward this maximum out-of-pocket amount. (The amount you pay for 
your Part D prescription drugs does not count toward your out-of-pocket maximum. In addition, amounts you 
pay for some services do not count toward your maximum out-of-pocket amount. These services are marked 
with an asterisk in the Medical Benefits Chart.) If you reach the maximum out-of-pocket amount of $6,700, 
you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part 
B services. You can find this information on page 56 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 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 $5 copayment for a PCP office visit. The Plan contract also says that 
enrollees must pay a $50 copayment for a specialist office visit. You can find this information on page 100 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. 
 
 
 
  
  Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. 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, Sections 
50.4.1 and 50.4.2. 
 
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 the usual maximum quantity of supplies for A7526 is 31 per month. You can find this rule in 
the Local Coverage Determination (LCD) - Tracheostomy Care Supplies (L33832) - Effective January 1, 2020. 
 
The rules say that the guidelines specify the maximum number of items/units of service that are usually 
reasonable and necessary. The actual quantity needed for a particular beneficiary may be more or less than the 
amount listed depending on clinical factors that affect the frequency of supply changes. The explanation for use 
of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiarys 
medical record. If adequate documentation is not provided when requested, the excess quantities will be denied 
as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) - 
Tracheostomy Care Supplies (L33832) - Effective January 1, 2020. 
 
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 $60 copayment for diagnostic radiology services performed at a non-
hospital facility. You can find this information on page(s) 107-108 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 repeat injections for shoulder arthritis are limited to a single repeat course. You can find 
this rule in the Local Coverage Article (LCA) for Billing and Coding: Hyaluronans Intra-articular Injections of 
(A52420). 
 
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 Centers for Medicare & Medicaid Services (CMS) covers TEER of the mitral valve 
under Coverage with Evidence Development (CED) with the following conditions: 
 
For the treatment of symptomatic moderate-to-severe or severe functional mitral regurgitation (MR) when the 
patient remains symptomatic despite stable doses of maximally tolerated guideline-directed medical therapy 
(GDMT) plus cardiac resynchronization therapy, if appropriate, or for the treatment of significant symptomatic 
degenerative MR when furnished according to a Food and Drug Administration (FDA)-approved indication 
and when specific criteria are met. You can find this rule in the Center for Medicare Services (CMS) 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 20.33. 
 
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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
 
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 non-emergency transportation by ambulance is appropriate if it is documented that the 
members condition is such that other means of transportation could endanger the persons health and that 
transportation by ambulance is medically required. You can find this information on page 5 of the Plan's 2022 
Schedule of Cost Sharing.
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 each power wheelchair code is required to include certain items on initial issue (i.e., no 
separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be 
separately billed does not necessarily indicate coverage. There is no separate billing/payment if fixed, 
swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may 
be billed separately. You can find this information in Local Coverage Article (LCA): Power Mobility Devices - 
Policy Article (A52498). 
 
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 split-night studies involve polysomnography in the first half of the night followed, if there is 
an abnormal frequency of apneas and hypopneas, by PAP titration for the remainder of the night. 
  
  Polysomnography with positive airway pressure (PAP) titration is indicated in patients with sleep apnea 
previously diagnosed by a clinical evaluation and either a positive PSG or a positive HST. Typically split-night 
studies are performed for two major reasons:  
 
1. When a positive diagnosis (described below) of sleep apnea (obstructive, central or mixed) can be made 
within the first 4 hours of polysomnography. This could include emergency protocols where patients apnea is 
not safe to continue testing without PAP treatment  
2. In patients with a prior history of OSA who need an updated polysomnography and PAP titration. 
 
You can find this information in the Local Coverage Determination (LCD) for Polysomnography and Sleep 
Testing (L33405). 
 
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 screening stool or fecal DNA (deoxyribonucleic acid, sDNA) testing detects molecular 
markers of altered DNA that are contained in the cells shed by colorectal cancer and pre-malignant colorectal 
epithelial neoplasia into the lumen of the large bowel. Through the use of selective enrichment and 
amplification techniques, sDNA tests are designed to detect very small amounts of DNA markers to identify 
colorectal cancer or pre-malignant colorectal neoplasia. The CologuardTM  multi-target sDNA test is a 
proprietary in vitro diagnostic device that incorporates both sDNA and fecal immunochemical test techniques 
and is designed to analyze patients stool samples for markers associated with the presence of colorectal cancer 
and pre-malignant colorectal neoplasia. 
 
Effective for dates of service on or after October 9, 2014, The CologuardTM test is covered once every three 
years for Medicare beneficiaries that meet all of the following criteria: 
 
Age 50 to 85 years, and, 
Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal 
pain, blood in stool, positive guaiac fecal occult blood test (gFOBT) or fecal immunochemical test (iFOBT)), 
and, 
At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, 
or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history of colorectal 
cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). 
 
Effective January 1, 2023, the minimum age for sDNA is reduced to 45 years and older. 
 
You can find this information in the National Coverage Determination (NCD) Colorectal Cancer Screening 
Tests 210.3. 
 
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 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 also says that there is a $750 deductible which applies to certain items and services. The Plan deductible applies to out-of-network (OON) outpatient diagnostic tests and lab services. You can find this information on pages 61-62 of the Plan's 2022 Evidence of Coverage (EOC).

The Plan contract also says that enrollees must pay 50% coinsurance for OON outpatient diagnostic tests and lab services. You can find this information on pages 86-88 of the Plan's 2022 EOC.

The Plan contract also says that enrollees must pay 50% coinsurance for an OON office visit. You can find this information on pages 93 of the Plan's 2022 EOC.