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 plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules state that the 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 (telehealth provided other than in patient's home), effective for 
claims with dates of service on or after January 1, 2021, that are processed on or after July 6, 2021: 99307, 
99308, 99309 and 99310. You can find this information in the centers for Medicare and Medicaid Services, 
Manual System, Publication 100-04 Medicare Claims Processing Manual Transmittal 10716. 
 
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 on page 28 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 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.  
 
The treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of parenteral 
nutrition. If the treating practitioner does not see the beneficiary within this timeframe, they must document the 
reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral 
nutrition needs. There must be documentation in the medical record supporting the clinical diagnosis. 
 
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. 
 
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 respiratory pathogen panels with more than 5 respiratory pathogens performed in the Part B 
outpatient setting are not considered medically necessary and reasonable and are therefore non-covered.  You 
can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination L39027 
entitled "Respiratory Pathogen Panel Testing." 
 
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 exclusion criteria for percutaneous vertebroplasty and percutaneous vertebral augmentation 
(PVA or Kyphoplasty) procedures include: 
        Absolute contraindication 
            Current back pain is not primarily due to the identified acute or subacute VCF(s). 
            Osteomyelitis, discitis or active systemic infection 
            Pregnancy 
            Active surgical site infection 
 
        Relative contraindication 
            Greater than three vertebral fractures per procedure 
            Allergy to bone cement or opacification agents 
            Uncorrected coagulopathy 
            Spinal instability 
            Myelopathy from the fracture 
            Neurologic deficit 
            Neural impingement 
            Fracture retropulsion/canal compromise 
 
You can find this information in the Local Coverage Determination (LCD) Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) L34976. 
 
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 state that a manual wheelchair for use inside the home (K0003) is covered if: 
 Criteria A, B, C, D, and E are met; and 
 Criterion F or G is met. 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. A mobility limitation is one that: 
    1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
    3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker. 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
D. Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in 
MRADLs and the beneficiary will use it on a regular basis in the home. 
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities 
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function. 
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each 
manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable 
and necessary. 
 A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria (1) and (2): 
1. Cannot self-propel in a standard wheelchair in the home; and 
2. The beneficiary can and does self-propel in a lightweight wheelchair. 
 
If the manual wheelchair base is not covered, then related accessories will be denied as not reasonable and 
necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Manual Wheelchair Bases 
(L33788). 
 
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 Molecular Diagnostic Services Program (MolDX) will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. You can find these rules in Local Coverage Determination 
(LCD) MolDX: Molecular Diagnostic Tests (MDT) L35025. 
 
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 exclusion criteria for percutaneous vertebroplasty and percutaneous vertebral augmentation 
(PVA or Kyphoplasty) procedures include: 
 
        Absolute contraindication 
            Current back pain is not primarily due to the identified acute or subacute VCF(s). 
            Osteomyelitis, discitis or active systemic infection 
            Pregnancy 
            Active surgical site infection 
        Relative contraindication 
            Greater than three vertebral fractures per procedure 
            Allergy to bone cement or opacification agents 
            Uncorrected coagulopathy 
            Spinal instability 
            Myelopathy from the fracture 
            Neurologic deficit 
            Neural impingement 
            Fracture retropulsion/canal compromise 
 
You can find this information in the 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.
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 pain of active trigger points can begin as an acute single muscle syndrome resulting 
from stress overload or injury to the muscle, or can develop slowly because of chronic or repetitive muscle 
strain. The pain normally refers distal to the specific hypersensitive trigger point. Trigger point injections are 
used to alleviate this pain. 
 
There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore upon 
the detailed history and thorough examination. The following diagnostic criteria are adopted by this A/B MAC 
from Simons.3 
 
Major criteria. All four must be present to establish the diagnosis. 
 
A. Regional pain complaint 
B. Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point 
C. Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it 
D. Some degree of restricted range of motion, when measurable. 
 
Minor criteria. Only one of four needed for the diagnosis. 
 
A. Reproduction of referred pain pattern by stimulating the trigger point 
B. Altered sensation by pressure on the tender spot 
C. Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot 
D. Pain alleviated by stretching or injecting the tender Spot 
 
The goal is to identify and treat the cause of the pain, not just the symptom. After making the diagnosis of 
myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are: 
 
    Medical management, which may include consultation with a specialist in pain medicine 
    Medical management that may include the use of analgesics and adjunctive medications, including anti-
depressant medications, shown to be effective in the management of chronic pain conditions.     Passive physical therapy modalities, including "stretch and spray" heat and cold therapy, passive range of 
motion and deep muscle massage. 
    Active physical therapy, including active range of motion, exercise therapy and physical conditioning. 
Application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger 
point is otherwise inaccessible). 
    Manipulation therapy. 
    Injection of local anesthetic, with or without corticosteroid, into the muscle trigger points. 
    a. as initial or the only therapy when a joint movement is impaired, such as when a muscle cannot be 
stretched fully or is in fixed position. 
 
    b. as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., exercise, 
use of medications, stretch and spray. 
 
You can find this information in the Local Coverage Determination (LCD) Trigger Point Injections L36859. 
 
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 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 Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, 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 these rules in National Coverage Determination (NCD) Next Generation Sequencing (NGS) 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 if a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so 1 procedure code 
must be submitted for the panel. This rule is found in Local Coverage Article: Billing and Coding: MolDX: 
Testing of Multiple Genes (A57880). 
 
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 Medicare covers application of CTPS to Ulcers or Wounds with Failed Response that are: 
 
    Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone or 
sinus tracts, with a clean granular base unless the CTP package label indicates the CTP is approved for use 
involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base ; 
    Skin deficit at least 1.0 cm2 in size; 
    Clean and free of necrotic debris or exudate; 
    Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by physical 
examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure > 30mm Hg); 
    For diabetic foot ulcers, the patients medical record reflects a diagnosis of Type 1 or Type 2 Diabetes and 
also reflects medical management for this condition. 
 
Wound healing is impaired by the systemic use of tobacco. Therefore, ideally patients who have smoked will 
have ceased smoking or have refrained from systemic tobacco intake for at least 4 weeks during conservative 
wound care and prior to planned bioengineered skin replacement therapy. 
 
You can find this information in the Local Coverage Determination (LCD) Wound Application of Cellular 
and/or Tissue Based Products (CTPs), Lower Extremities L36690. 
 
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 state that the following provider types are eligible to receive Medicare payment: physicians, 
physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, and clinical psychologists.  You 
can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-02, Medicare 
Benefit Policy Manual Chapter 15, 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.
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 20% coinsurance for out-of-network Medicare Part B drugs. You can find 
this information on pages 74-76 of the Plan's 2023 Evidence of Coverage (EOC).  
 
The Plan contract also says that enrollees must pay 20% coinsurance for out-of-network diagnostic tests and 
procedures. You can find this information on pages 77-78 of the Plans 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 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 $375 copayment per day for days 1-5 of each inpatient hospital stay. 
Enrollees then pay a $0 copayment per day for days 6-90 of each inpatient hospital stay. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. You can find this information on pages 78-81 of the Plan's 2022 Evidence 
of Coverage (EOC).