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 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 a provider/supplier may report only one new patient code on a single date of service. You 
can find this information in Medicares National Correct Coding Initiative Policy Manual, Chapter XI 
Medicine Evaluation and Management Services Cpt Codes 90000  99999, Section U. Evaluation & 
Management (E&M) Services. 
 
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. 
 
The rules also say that when reporting an encounter/visit for payment, the federally qualified health center 
(FQHC) must bill on the claim a FQHC specific payment code, which is a G-code. FQHCs must report HCPCS 
coding on the claim to describe all services that occurred during the encounter. All service lines must be 
reported with their associated charges. The additional services reported on the claim that are part of the FQHC 
encounter, will not be paid. The payment for these services is included in the payment under the FQHC 
payment code. You can find this information in the Centers for Medicare and Medicaid Services (CMS), 
Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.  
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 enrollees pay a $60 copayment for out-of-network specialist services. You can find this 
information on page 120 of the Plans 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 a Group 2 Single Power Option power wheelchair (PWC) (K0835, K0836, K0837, K0838, 
K0839, K0840) is covered if all of the basic coverage criteria for a PWC are met and if:  
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met.  
1. The beneficiary requires a drive control interface other than a hand or chin-operated 
standard proportional joystick (examples include but are not limited to head control, sip 
and puff, switch control). 
2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system 
(see Wheelchair Options/Accessories policy for coverage criteria) and the system is 
being used on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical therapist (PT) or occupational therapist (OT), or 
practitioner who has specific training and experience in rehabilitation wheelchair 
evaluations and that documents the medical necessity for the wheelchair and its special 
features (see Documentation Requirements section). The PT, OT, or practitioner may 
have no financial relationship with the supplier. 
4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and 
Assistive Technology Society of North America (RESNA) certified Assistive 
Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-
person involvement in the wheelchair selection for the beneficiary. 
If a Group 2 Single Power Option PWC is provided and if criterion (A) or (B) is not met (including but 
not limited to situations in which it is only provided to accommodate a power seat elevation feature, a 
power standing feature, or power elevating legrests), it will be denied as not reasonable and necessary. 
  If the PWC base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD) for Power Mobility Devices 
(L33789). 
 
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 botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered medically 
reasonable and necessary when administered for treatment of Food & Drug Administration (FDA)-labeled 
indications and Off-label indications (as applicable) below: 
1. FDA indications for onabotulinumtoxinA (Botox) as noted on the FDA website 
2. Off-Label indications for onabotulinumtoxinA (Botox) may be considered medically reasonable and 
necessary in patients for the following conditions: 
- Esophageal achalasia in adults who are considered poor surgical candidates 
- Chronic anal fissure for patients with inadequate response to conservative or pharmacologic 
treatment 
- Essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily 
living and have had inadequate response to oral pharmacotherapy such as propranolol and 
primidone 
- Focal limb dystonia 
- Hemifacial spasm in adults (cranial nerve VII disorder) 
- Isolated oromandibular dystonia in adults 
- Laryngeal dystonia (spastic dysphonia) for adductor type (ADSD) 
- Bothersome simple motor tics in adolescents and adults when the benefits of treatment outweigh 
the risks 
- Severely disabling or aggressive vocal tics in older adolescents and adults when the benefits of 
treatment outweigh the risks 
 
Localization procedures would not be expected for easily targeted muscles and, therefore, would not be 
considered medically reasonable and necessary. Cosmetic procedures are not a covered benefit under Medicare. 
Treatment of wrinkles, also referred to as glabellar lines, smokers lines, crows feet, laugh lines and aging 
neck, using botulinum toxins is considered to be a cosmetic procedure, and is not covered under Medicare. You 
can find these rules in Local Coverage Determination (LCD) Botulinum Toxins (L38809). 
 
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 effective for services performed on or after March 16, 2018, the Centers for Medicare & 
Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory 
test is reasonable and necessary and covered nationally for somatic (acquired) cancer, when performed in a 
Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating 
physician, and when all of the following requirements are met: 
 
   a. Patient has: 
i. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and 
ii. not been previously tested with the same test using NGS for the same cancer genetic content, and 
iii. decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
   b. The diagnostic laboratory test using NGS must have: 
i. Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, 
ii. an FDA-approved or -cleared indication for use in that patients cancer; and, 
iii. results provided to the treating physician for management of the patient using a report template to specify 
treatment options. 
 You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual: Next Generation Sequencing (NGS) 
NCD 90.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that disposable drug delivery systems, including elastomeric infusion pumps are non-covered 
devices because they do not meet the Medicare definition of durable medical equipment. Drugs and supplies 
used with disposable drug delivery systems are also non-covered items. You can find this rule in Local 
Coverage Article (LCA) 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 that 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. 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. 
 
Erythropoiesis Stimulating Agent (ESA) treatment for the anemia secondary to myelosuppressive anticancer 
chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia is only reasonable 
and necessary when the hemoglobin level immediately prior to initiation or maintenance of ESA treatment is 
less than 10 grams per deciliter (or the hematocrit is less than 30%). You can find this rule in the National 
Coverage Determination (NCD) for Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related 
Neoplastic Conditions (110.21). 
 
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 and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
The rules say that if contractors have evidence (for example, medical review) that unit of service (UOS) in 
excess of the medically unlikely edits (MUE) value were actually  provided, were correctly coded and were 
medically necessary, the contractor may bypass the MUE for a Healthcare Common Procedure Coding System 
(HCPCS) code with an MUE Adjudication Indicator (MAI) of 3 during claim processing, reopening, or 
redetermination, or in response to effectuation instructions from a reconsideration or higher-level appeal. You 
can find this information in Medicare's National Correct Coding Initiative Policy Manual (NCCI), Chapter 1, 
Section V. Medically Unlikely Edits (MUEs). 
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. MUEs for codes with an MAI of 3 are per day edits based on clinical 
benchmarks. Codes with an MAI of 3 are based on criteria combined with data such that it would be 
possible, but medically unlikely, that higher values would represent correctly reported medically necessary 
services. To be paid, there must be evidence (e.g., medical review) that the excess units were actually provided, 
were correctly coded, and were medically necessary. 
 
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(V).  
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 pages 78-79 in 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 services with status indicator N are paid under the Outpatient Prospective Payment System 
(OPPS), but their payment is packaged into payment for a separately paid service. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual Chapter 4, Section 10.1.1. 
 
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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 28 to 29 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 Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with 
Multiple Power Options (K0861, K0862, K0863, K0864) is covered if:  
A. All of the basic coverage criteria for a power wheelchair (PWC) are met; and the beneficiary's 
mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity; and 
B. Criterion 1 or 2 is met; and Criteria 3 and 4 are met.  
1. The beneficiary requires a drive control interface other than a hand or chin-operated 
standard proportional joystick (examples include but are not limited to head control, sip 
and puff, switch control). 
2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system 
(see Wheelchair Options/Accessories policy for coverage criteria) and the system is 
being used on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical therapist (PT) or occupational therapist (OT), or 
practitioner who has specific training and experience in rehabilitation wheelchair 
evaluations and that documents the medical necessity for the wheelchair and its special 
features (see Documentation Requirements section). The PT, OT, or practitioner may 
have no financial relationship with the supplier. 
4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and 
Assistive Technology Society of North America (RESNA) certified Assistive 
Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-
person involvement in the wheelchair selection for the beneficiary. 
 
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion (A) or 
(B) is not met, it will be denied as not reasonable and necessary. If the PWC base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD) for Power Mobility Devices 
(L33789). 
 
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. 
 
The rules also say that the dose and frequency of administration should be consistent with the FDA approved 
labeling. 
It is expected that an injection (Synvisc-One TM, Gel-One, Durolane) or course of the injections (Synvisc, 
Hyalgan, Supartz or Visco-3TM, EuflexxaTM, Orthovisc, GelSyn-3TM, GenVisc 850, Hymovis, 
TriViscTM, 
SynojoyntTM, TriluronTM) will not be repeated within six months time. 
 
A repeat series of injections may be allowed when: 
 
1. The indications continue to be met; and 
2. Significant improvement in pain and functional capacity from the prior series of injections is documented in 
the 
medical record; and 
3. The last injection (in a prior course) was given at least six (6) months ago. 
 
Repeat injections for shoulder arthritis are limited to a single repeat course. 
 
You can find this rule in Local Coverage Article (LCA) 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.