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 Medicare is creating additional flexibilities to allow licensed independent freestanding 
emergency departments (EDs) to participate in Medicare and Medicaid to help address the urgent need to 
increase hospital capacity to provide care to patients. The following ways to participate include: 
1. Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 
emergency waiver. 
2. Participating in Medicaid under the clinic benefit if permitted by the State, or 
3. Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services 
You can find this information in The Centers for Medicare and Medicaid Services (CMS) Guidance for 
Licensed Independent Freestanding Emergency Departments (EDs) to Participate in Medicare and Medicaid 
during the COVID-19 Public Health Emergency. 
 
The rules say that Medicare covers services in an emergency department only if the emergency clinic is 
affiliated with a hospital. You can find this rule at SSA 1861, 42 CFR 489.24, and 42 CFR 413.65. 
 
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 respiratory pathogen panel test is a single service with a single unit of service. A 
respiratory pathogen panel 
test must not be unbundled and billed as individual components regardless of the fact that the panel reports 
multiple individual pathogens and/or targets. This rule is found in Local Coverage Article: Billing and Coding: 
Respiratory Pathogen Panel Testing (A58575). 
 
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 certain cardiac event monitors capture electrical activity with a single electrode attached to 
the skin. Other devices may employ multiple electrodes in order to record more complex electrocardiogram 
tracings. Additionally, devices may be individually programmed to detect patient-specific factors, electrode 
malfunction, or other factors. Cardiac event monitors can be further categorized as either pre-event or post-
event recorders, based on their memory capabilities: 
 
    - Pre-symptom Memory Loop Recorder (MLR) 
 
       Upon detecting symptoms, the wearer presses a button, which activates the recorder to save (i.e., 
memorize) an interval of pre-symptom EKG data along with data during and subsequent to the symptomatic 
event. Self-sensing recorders (also known as event-activated or automatic trigger) do not require patient input 
to capture these data. Single or multiple events may be recorded. The device is worn at all times, usually for up 
to 30 days. 
          - Implantable (or Insertable Loop) Recorder (ILR)  
       Another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left chest and may 
remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related, but is too 
infrequent to be detected by either a Holter monitor or a traditional pre-symptom MLR. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-03, National Coverage Determination (NCD) for Electrocardiographic Services (20.15). 
 
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. 
 
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 the 
requested item or service but is limited to one every 5 years. You can find this information on pages 98-101 of 
the Plan's 2023 Evidence of Coverage (EOC) and in the Quick Reference Guide.
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 pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 24 one-way trips to plan approved locations every year. You can find this information on page 54 
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 state that the Medicare Common Working File (CWF) shall revise the current line level edits from 
once every 30 days to only allow a frequency of one every 14 days for the following codes when billed with the 
-GT or -GQ modifier or Place of Service (POS) code 02: 
- 99307 
- 99308 
- 99309 
- 99310 
 
You can find this rule in Centers for Medicare and Medicaid Services (CMS) Publication 100-04 Medicare 
Claims Processing Transmittal 10716 Common Working File (CFW) Edits for Medicare Telehealth Services 
and Manual Update. 
 
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 it has not been established that a moist electric heating pad (E0215) or water circulating heat pad 
with pump (E0217) is reasonable and necessary compared to a standard electric heating pad (E0210); therefore, 
if code E0215 or E0217 is provided it will be denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Heating Pads and Heating Lamps 
(L33784). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that beneficiaries do not have to be discharged within the period because of admissions to other 
types of health care providers (i.e., hospitals, skilled nursing facilities). If an agency chooses not to discharge 
and the patient returns to the agency in the same 30-day period, the same period of care continues. All the HH 
services provided in the complete period of care, both before and after the inpatient stay, should be billed on 
one claim. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.14. 
 
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 modifiers were established to simplify billing for visits and other procedures which are 
furnished during the postoperative period of a surgical procedure, which are not included in the payment for the 
surgical procedure. 
- Modifier -79: Reports an unrelated procedure by the same physician during a postoperative period. 
- Modifier -24: Reports an unrelated evaluation and management service by the same physician during a 
postoperative period 
 
You can find this rule in Medicare Claims Processing Manual Chapter 12, Section 40.2. 
 
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 after the first diagnostic facet joint procedure, there must be a consistent positive response of 
at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38765). 
 
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 percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 
1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have 
not responded to non-surgical medical management (narcotic and/or non- narcotic medication, physical 
therapy modalities) with and without methods of immobility (rest, bracing). 
A. Both PVP and PVA will be considered reasonable and necessary when all of the following 
criteria are met: 
i. Acute (less than 6 weeks) or subacute (6-12 weeks)
 
osteoporotic vertebral compression 
fracture (VCF) (T1 L5), based on symptom onset, and documented by advanced 
imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT 
uptake and 
ii. The beneficiary is symptomatic and is hospitalized with severe pain or is non-
hospitalized with moderate to severe pain despite optimal non-surgical management 
(NSM) with one of the following: 
a. Worsening Pain or 
b. Stable to improved pain when 2 or more of the following are present: 
- Progression of vertebral body height loss 
- > 25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
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 cardiovascular nuclear imaging is indicated for the following: 
 
Assessment of the functional and prognostic importance of angina; 
 
Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal electrocardiogram (ECG) 
changes caused by drugs, bundle branch block, or left ventricular hypertrophy; 
 
Assessment of congenital anomalies of coronary arteries; 
 
Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with 
known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a 
revascularization procedure within the past two years; 
 
Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed 
heart failure or left ventricular systolic dysfunction; 
 
Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary 
angiography are not planned; 
 
Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-
perfusion procedures; 
 
Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; 
 
 
  Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative 
management in: 
 patients with minor or intermediate clinical risk predictors and poor functional capacity; 
 patients with intermediate or high likelihood of coronary heart disease, or 
 patients with poor functional capacity undergoing high risk non-cardiac surgery; 
Evaluation of ventricular function in patients with non-ischemic myocardial disease; 
 
Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination 
of whether to implant a defibrillator or biventricular pacemaker; 
 
Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin). 
 
First pass studies will be considered medically necessary only when information sought is immediately relevant 
to the management of the patients clinical condition, and has not been previously obtained or likely to be 
obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First pass 
studies may be indicated for the assessment and identification of shunts. 
 
Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of 
myocardial infarction by electrocardiogram (EKG) or enzyme testing. 
 
You can find this information in the Local Coverage Determination (LCD) for Cardiovascular Nuclear 
Medicine (L33560). 
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 under Group 1 Paragraph, Targeted Respiratory Panels - These codes are covered under 
limited circumstances: Group 1 Codes: 0240U. You can find this rule in Local Coverage Article, Billing and 
Coding: MolDX: Molecular Syndromic Panels for Infections Disease Pathogen Identification Testing 
(A58761). 
 
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 21 to 22 of the Plans 2022 Schedule of Cost Sharing.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 critical care is a time-based service, and therefore, practitioners must document in the 
medical record the total time (not necessarily start and stop times) that critical care services are furnished by 
each reporting practitioner. Documentation needs to indicate that the services furnished to the patient, including 
any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and/or 
treatment of illness and/or injury or to improve the functioning of a malformed body member. When a single 
physician furnishes 30-74 minutes of critical care services to a patient on a given date, the physician will report 
CPT code 99291. CPT code 99291 will be used only once per date even if the time spent by the practitioner is 
not continuous on that date. Thereafter, the physician will report CPT code 99292 for additional 30-minute 
time increments provided to the same patient. You can find these rules in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 
12, Sections 30.6.12.2, and 30.6.12.8. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. You can find this rule in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 20.9. 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.