Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules state that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This 
involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new 
Patient-Driven Payment Model (PDPM), which is effective for services provided on or after 10/1/2019, the 
HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under 
the revised model. The first position represents the Physical and Occupational Therapy case-mix group. The 
second position represents the Speech-Language Pathology (SLP) case-mix group. The third character 
represents the nursing case-mix group. The fourth character represents the Non-Therapy Ancillary (NTA) case-
mix group. The fifth character represents the assessment indicator code. You can find this information in the 
Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, Medicare Claims Processing 
Manual, Chapter 6, Sections 10, 30, and 120. 
 
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. 
 
The rules say that a health plan must disclose to enrollees, in clear accurate terms, the benefits offered under a 
plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes two 
cleanings every 12 months. You can find this information in Chapter 4 on page 59 of the Plans 2023 Evidence 
of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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). 
 
Additionally, the rules state that when services are furnished in a mobile unit, they are often provided to serve 
an entity for which another place of service (POS) code exists. For example, a mobile unit may be sent to a 
physician's office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS 
code already exists, providers should use the POS code for that entity. However, if the mobile unit is not 
serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit 
POS code 15. You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only 
Manual, Publication Number 100-04, Medicare Claims Processing Manual, Chapter 26, 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 if medically necessary and reasonable, Medicare will cover one Fluorodeoxyglucose (FDG) 
Positron Emission Tomography (PET) scan to determine the initial level of cancer treatment needed for an 
enrollee. After the completion of the initial anti-cancer therapy, additional FDG PET scans may be covered at 
the discretion of Medicare. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, National Coverage Determinations Manual, Section 220.6.17. 
 
The rules say that with the exception of suspected prostate cancer, Medicare covers one Fluorodeoxyglucose 
(FDG) Positron Emission Tomography (PET) scan when medically necessary and reasonable to help determine 
the initial treatment strategy for enrollees suspected of having cancer. Medicare may also cover up to three 
FDG PET scans when used to guide subsequent management of cancer treatment after completion of initial 
anti-cancer therapy. The local Medicare Administrative Contractor may determine if more than three scans are 
coverable. Some limitations apply when FDG PET scan is used for initial diagnosis or staging of melanoma or 
of cancers of the cervix or breast. You can find this rule in the National Coverage Determinations Manual, 
Section 220.6.17. 
 
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 for parenteral nutrition to be considered reasonable and necessary, the treating practitioner 
must document that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that 
EN exacerbates gastrointestinal tract dysfunction. The beneficiary must have (a) a condition involving the 
small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or (b) disease 
of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported 
through and absorbed by the gastrointestinal (GI) system. The beneficiary must have a permanent impairment. 
Please refer to the LCD-related Policy Article for further guidance regarding the test of permanence. 
 
You can find this information in the Local Coverage Determination (LCD) Parenteral Nutrition L38953. 
 
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 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 Plan 
contract includes a list of covered supplemental dental services. The contract specifically says that any 
procedure not listed is not covered. Problem focused limited oral evaluation (D0140), first intraoral periapical 
x-ray (D0220), additional intraoral periapical x-ray (D0230), and simple extraction (D7140) are not included 
on this list and are not covered supplemental benefits. You can find this information on pages 91 to 96 of the 
Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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 mastectomy with nipple preservation or reduction mammoplasty is considered reconstructive 
and medically reasonable and necessary for males with gynecomastia Grade III and IV as defined on the 
American Society of Plastic Surgeons (ASPS) gynecomastia scale or symptomatology or signs of deformity 
related to excess size. You can find this information in the Local Coverage Determination (LCD): Cosmetic 
and Reconstructive Surgery (L35090). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 71 of the Plan's 2023 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 state that the following medical items, supplies, and services furnished to inpatients are covered 
under Part A. Consequently, they are covered by the prospective payment rate or reimbursed as reasonable 
costs under Part A to hospitals excluded from prospective payment system (PPS). 
-Laboratory services (excluding anatomic pathology services and certain clinical pathology services); 
-Pacemakers and other prosthetic devices including lenses, and artificial limbs, knees, and hips; 
-Radiology services including computed tomography (CT) scans furnished to inpatients by a physician's office, 
other hospital, or radiology clinic; 
-Total parenteral nutrition (TPN) services; and 
-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. 
 
The hospital must include the cost of these services in the appropriate ancillary service cost center, i.e., in the 
cost of the diagnostic or therapeutic service. It must not show them separately under revenue code 0540. 
You can find this rule in the Centers for Medicare & Medicaid Service, Medicare Claims Processing Manual, 
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. You can find this rule in the Centers for Medicare & Medicaid 
Service, Medicare Claims Processing Manual, 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 state that NMES involves the use of a device which transmits an electrical impulse to the skin over 
selected muscle groups by way of electrodes. There are two broad categories of NMES. One type of device 
stimulates the muscle when the patient is in a resting state to treat muscle atrophy. The second type is used to 
enhance functional activity of neurologically impaired patients. Coverage of NMES to treat muscle atrophy is 
limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal 
cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. You can find this in the 
Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication Number 100-03, Medicare 
National Coverage Determinations Manual, Section 160.12. 
 
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 UV light therapy systems are covered for selected patients with generalized intractable 
psoriasis. You can find this information in the National Coverage Determination (NCD): Durable Medical 
Equipment Reference List (280.1). 
 
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 state that a gradient compression wrap is only covered when it is used as a primary or secondary 
dressing over wounds that meet the statutory requirements for a qualifying wound (surgically created or 
modified, or debrided). 
 
Claims for gradient compression wraps used without a qualifying wound or when used for other non-qualifying 
conditions will be denied as statutorily non-covered, no benefit. Refer to the related Policy Article NON-
MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about the statutory benefit 
requirements 
 
You can find this information in the Local Coverage Determination (LCD) Surgical Dressings L33831. 
 
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 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 (CMS), 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.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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. 
 
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 Grievance 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 state that monoclonal antibodies directed against amyloid for the treatment of Alzheimers Disease 
provided outside of a Food & Drug Administration (FDA) approved randomized controlled trial, Medicare-
approved study, or study supported by the National Institutes of Health (NIH) are nationally non-covered. You 
can find this rule in National Coverage Determination (NCD) Monoclonal Antibodies Directed Against 
Amyloid for the Treatment of Alzheimers Disease (AD) (200.3). 
 
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 claim lines billed with codes without a KX, GA or GZ modifier will be rejected as missing 
information. This rule is found in Local Coverage Article: Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy 
Article (A52457). 
 
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
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.