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 4Kscore test will be considered medically reasonable and necessary when all the following are met: 
1. When all of the components of the algorithm are present. 
2. Testing of men 45 years of age and older, prior to an initial biopsy or following a negative biopsy, who 
have a confirmed* moderately elevated prostate-specific antigen (PSA) (greater than 3 and less than 
10 ng/mL; greater than or equal to 4 and less than 10 ng/mL in men greater than 75 years of age) when 
BOTH of the following are present: 
o No other relative indication** for prostate biopsy including ANY of the following: (this may not 
be an all inclusive list)  
 digital rectal examination (DRE) suspicious for cancer should be encouraged to undergo 
biopsy 
 Persistent and significant increase in PSA should be encouraged to undergo biopsy 
 Positive multiparametric magnetic resonance imaging (MRI) (if done) 
 Other major risk factor for prostate cancer including: (this may not be an all inclusive 
list)  
 Ethnicity at higher risk for prostate cancer 
 First-degree relative with prostate cancer 
 High-penetrance prostate cancer risk gene(s) per the National Comprehensive 
Cancer Network (NCCN) (if known) 
o No other relative contraindication** for prostate biopsy including ANY of the following:  
 Less than a 10-year life expectancy 
 Benign disease not ruled out. 
    3.  Presence of shared decision making between the ordering provider and the beneficiary concerning 
the 4Kscore testing. 
You can find this rule in the Local Coverage Determination (LCD): 4Kscore Test Algorithm (L37792). 
 
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 all services integral to accomplishing a procedure are considered bundled into that procedure 
and, therefore, are considered a component part of the comprehensive code. Many of these generic activities 
are common to virtually all procedures and, on other occasions, some are integral to only a certain group of 
procedures but are still essential to accomplish these particular procedures. Accordingly, it is inappropriate to 
separately report these services based on standard medical and surgical principles. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication Number 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 30(a). 
 
The rules say that a therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for 
the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is 
not separately payable. If performed to facilitate the infusion or injection or hydration, the following services 
and items are included and are not separately billable: 
1. Use of local anesthesia; 
2. IV start; 
3. Access to indwelling IV, subcutaneous catheter or port; 
4. Flush at conclusion of infusion; and 
5. Standard tubing, syringes and supplies. 
Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy 
injection and infusion service. 
 
You can find this information in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.5 and 40.1.C. 
 
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 plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 1, Section 20.2. 
 
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, 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 in Chapter 3 on pages 32 and 33 
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 state that all End Stage Renal Disease (ESRD) claims with dates of service on or after July 1, 2010, 
must indicate the applicable Kt/V (a measure of dialysis adequacy) reading for the dialysis patient. The reading 
result and the date of the reading must be reported on the claim using the following claim code:  
Value Code D5 - Result of last Kt/V reading. For in-center hemodialysis patients this is the last reading taken 
during the billing period. For peritoneal dialysis patients and home hemodialysis this may be before the current 
billing period but should be within 4 months of the claim date of service. You can find this information in the 
Centers for Medicare & Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 8, 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 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 $300 copayment for inpatient hospital services. Each time you are 
admitted to an acute care hospital, you pay $300. You will not pay more than $900 for inpatient hospital 
covered services in a calendar year. You can find this information on page(s) 82 of the Plan's 2023 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 infusion drugs started in a practitioners office, whether with or without a pump, must be 
billed to the local carrier and not the DME MAC. In these cases, the drug or biological may potentially be 
covered under section 1861(s)(2)(A) and (B) of the Act and is billable to the A/B MAC even though the entire 
administration of the drug or biological did not occur in the practitioners office or the hospital outpatient 
department. Equipment, such as an external infusion pump used to begin administration of the drug or 
biological that the patient takes home to complete the infusion, is not separately billable as durable medical 
equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit. These 
claims will be rejected as wrong jurisdiction.  
An ambulatory infusion pump (E0781) is an electrical or battery-operated device, which is used to deliver 
solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed 
to be carried by the beneficiary. You can find these rules in Local Coverage Article External Infusion Pumps - 
Policy Article A52507. 
 
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 $325 copayment for in-network inpatient hospital care. the enrollee 
must pay a $325 copayment per day, for days one to six, for each inpatient hospital stay. There is a $0 
copayment for additional days after day six. You can find this information on page(s) 84 of the Plan's 2023 
Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
  
  The rules say that a Medicare Plan is financially responsible for emergency services regardless of whether the 
services are obtained within or outside the Plan. Emergency services are covered whether there is prior 
authorization for the services. An emergency is defined as when a person would believe that without immediate 
medical attention there would be serious jeopardy to his or her health. You can find this rule at 42 CFR Section 
422.113(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.
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 & 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 61 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 $30 copayment for outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 67 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 $400 copayment for inpatient hospital care. The enrollee must pay a 
$400 copayment per day, for days one to four, for each inpatient hospital stay. There is a $0 copayment for 
additional days after day four. You can find this information on page(s) 56 to 58 of the Plan's 2023 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $100 copayment for outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 91 to 92 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 code J2274 is only used for morphine sulfate that is labeled "preservative free. Morphine 
sulfate that is not labeled "preservative free" must be coded J2270. You can find this rule in the Local Coverage 
Article (LCA) - External Infusion Pumps - Policy Article (A52507). 
 
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. 
 
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 & 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.
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 $350 copayment for outpatient surgery/Medicare-coveredsurgery.  You 
can find this information on page(s) 87 of the Plan's 2023 Evidence of Coverage.