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 state that definitive UDT is reasonable and necessary for the following circumstances: 
 
-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
-Definitively identify specific drugs in a large family of drugs; 
-Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, -
Meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
-Identify drugs when a definitive concentration of a drug is needed to guide management  
-Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self- 
report, presentation, medical history, or current prescribed pain medication plan; 
-Rule out an error as the cause of an unexpected presumptive UDT result; 
-Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
-Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, 
medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. 
The clinicians rationale for the definitive UDT and the tests ordered must be documented in the patients 
medical record. 
 
You can find this information in Local Coverage Determination (LCD): Controlled Substance Monitoring and 
Drugs of Abuse Testing (L36393), 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
 
The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the 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 
The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or 
The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 
60 days, 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". 
 
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. 
 
A support surface which does not meet the characteristics specified in the Coding Guidelines section of the 
Pressure Reducing Support Surfaces  Group 2 Policy Article will be denied as not reasonable and necessary. Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, 
there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified 
to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound 
management. 
 
You can find these rules 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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. 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 10.  
 
The rules state that a type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An 
Excludes1 note indicates that the code excluded should never be used at the same time as the code above the 
Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form 
versus an acquired form of the same condition. You can find this information in the ICD-10-CM Official 
Guidelines for Coding and Reporting, Section I. Conventions, general coding guidelines and chapter specific 
guidelines.  
 
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. 
 
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 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. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
Licensed Mental Health Counselors frequently attempt to enroll in Medicare but are not eligible to do so; no 
statute permits them to bill Medicare. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 
10.2.8 
 
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 under Section 1862(a)(2) of the Social Security Act (the Act), the Medicare program 
does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or 
organization has a legal obligation to provide or pay for that service. Also, under Section 1862(a)(3) of the Act, 
if services are paid for directly or indirectly by a governmental entity, Medicare does not pay for the services. 
These provisions are implemented by regulations 42 C.F.R. 411.4, 411.6, and 411.8, respectively. 
 
The regulation at 42 CFR 411.4(b) states: Individuals who are in custody include, but are not limited to, 
individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised 
release, on medical furlough, required to reside in mental health facilities, required to reside in halfway houses, 
required to live under home detention, or confined completely or partially in any way under a penal statute or 
rule. 
 
The definition of custody is in accordance with how custody is defined by Federal courts for purposes of the 
habeas corpus protections of the Constitution. For example, the term custody is not limited solely to physical 
confinement. (Sanders v. Freeman,221F.3d 846, 850-851 (6PthP Cir. 2000).) Individuals on parole, probation, 
bail, or supervised release may be in custody. 
 
42 CFR 411.4(b) goes on to describe the special conditions that must be met in order for Medicare to make 
payment for individuals who are in custody, 42 CFR 411.4(b) states: Payment may be made for services 
furnished to individuals or groups of individuals who are in the custody of the police or other penal authorities 
or in the custody of a government agency under a penal statute only if the following conditions are met: (1) 
State or local law requires those individuals or groups of individuals to repay the cost of medical services they 
receive while in custody. (2) The State or local government entity enforces the requirement to pay by billing all 
such individuals, whether or not covered by Medicare or any other health insurance, and by pursuing the 
collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of 
other debts.  
You can find this rule in the Medicare Claims Processing Manual, Chapter 1, Section 10.4. 
 
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 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. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2.  
 
Mental Health Counselors frequently attempt to enroll in Medicare but are not eligible to do so; no statute 
permits them to bill Medicare. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 
10.2.8 
 
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 oxygen and oxygen equipment, Medicare pays a monthly fee schedule amount per 
beneficiary. Fee schedule payments for stationary oxygen system rentals are all inclusive and represent a 
monthly allowance per beneficiary. Accordingly, a supplier must bill on a monthly basis for stationary oxygen 
equipment and contents furnished during a rental month. You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
20, Section 30.6 and 130.6. 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) L35160 and the related Local Coverage Article: Billing and Coding: MolDX: 
Molecular Diagnostic Tests (MDT) A57526.  
 
The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
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.
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 modifiers are used to identify therapy services whether or not financial limitations are in 
effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy 
modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of 
applicable therapy codes except as noted in 20 of this chapter. Consult 20 for the list of codes to which 
modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not 
qualified and recognized by Medicare to perform. The claim must include one of the following modifiers to 
distinguish the discipline of the plan of care under which the service is delivered: 
-GP Services delivered under an outpatient physical therapy plan of care. 
 
You can find this rule in the Medicare Claims Processing Manual, Chapter 5, Section 20.1. 
 
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 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 plans 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.  
 
The rules also say that if a Medicare Advantage (MA) plan decides to adopt and apply step therapy to Part B 
drugs, the MA plan must disclose that Part B drugs may be subject to step therapy requirements in the plans 
Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents. You can find this information 
in the CMS Memo: Prior Authorization and Step Therapy for Part B Drugs in Medicare Advantage. 
 
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 STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. You 
can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare 
Claims Processing Manual Chapter 4, Section 10.4. 
 
The rules say that the Outpatient Prospective Payment System (OPPS) assigns status indicators to codes to 
indicate payment rules associated with those codes. Codes with a status indicator of N are considered Items and 
Services Packaged into Ambulatory Payment Classification (APC) Rates. This means that payment is packaged 
into payment for other services, including outliers. There is no separate APC payment for codes with this status 
indicator.  You can find this rule at Centers for Medicare and Medicaid Services, Addendum D1.--Proposed 
Payment Status Indicators. 
 
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).  
 
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 $1,000 deductible, which applies to certain items and services. The Plan 
deductible applies to most of your covered services. You can find this information on pages 53 and 54 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 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 $250 copayment for outpatient hospital services.  You can find this 
information on page(s) 87 to 89 of the Plan's 2023 Evidence of Coverage.