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 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 $10 copayment for a primary care office visit, within the 
physician/practitioner services, including doctor's office visits. You can find this information in Chapter 4 on 
page 110 of the Plan's 2022 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that changes in mental illness may require psychological testing to determine new diagnoses or 
the need for changes in therapeutic measures. Repeat testing not required for diagnosis or continued treatment 
would be considered medically unnecessary. Nonspecific behaviors that do not indicate the presence of, or 
change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric 
evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would 
not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment 
reactions or dysphoria associated with moving to a nursing facility do not constitute medical necessity for 
psychological testing. 
 
The rules say that neuro-cognitive, mental status, and speech testing is testing which is intended to diagnose 
and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 
Examples of problems that might lead to neuropsychological testing are: 
 
    Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head 
injury, anoxic injuries, AIDS dementia) 
    Differential diagnosis between psychogenic and neurogenic syndromes 
    Delineation of the neurocognitive effects of central nervous system disorders 
    Neurocognitive monitoring of recovery or progression of central nervous system disorders; or 
    Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies 
among individuals with neuropsychiatric disorders. 
 
You can find this information in the Local Coverage Determination (LCD) for Psychiatry and Psychology 
Services (L33632). 
 
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 exploration of the surgical field is a standard surgical practice. Providers/suppliers shall not 
report a HCPCS/CPT code describing exploration of a surgical field with another HCPCS/CPT code describing 
a procedure in that surgical field. For example, CPT code 22830 describes exploration of a spinal fusion. CPT 
code 22830 shall not be reported with another procedure of the spine in the same anatomic area. However, if 
the spinal fusion exploration is performed in a different anatomic area than another spinal procedure, CPT code  
22830 may be reported separately with modifier 59 or XS. You can find this information in the National 
Correct Coding Initiative (NCCI) Policy Manual for Medicare Services; Chapter IV Surgery: Musculoskeletal 
System CPT Codes 20000-29999: F. Spine (Vertebral Column). 
 
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 fluorodeoxyglucose (FDG) PET scan is considered reasonable and necessary in patients 
with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet 
diagnostic criteria for both Alzheimer's disease (AD) and fronto-temporal dementia (FTD). You can find this 
rule in the National Coverage Determinations Manual, Section 220.6.13. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d). 
 
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 you may receive a routine hearing exam, a hearing aid fitting/evaluation, and one hearing aid, per 
ear, per year from any network hearing or hearing aid provider. You can find this information on page 86 of the 
Plan's 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 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 pharmacogenetics testing will be considered medically reasonable and necessary if: 
 
1. The patient has a condition where clinical evaluation has determined the need for a medication that has a 
known gene-drug interaction(s) for which the test results would directly impact the drug management of the 
patients condition; AND 
2. The test meets evidence standards for genetic testing as evaluated by a scientific, transparent, peer-reviewed 
process and determined to demonstrate actionability in clinical decision making by CPIC guideline level A or 
B1; or is listed in the Food and Drug Administration (FDA) table of known gene-drug interactions where data 
support therapeutic recommendations or a potential impact on safety or response or the FDA label. 
  
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): Pharmacogenomics Testing (L39063). 
 
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 clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator 
who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise 
activity that demands prosthetic utilization beyond simple locomotion. 
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. 
 
A fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for beneficiaries 
whose functional level is 3 or above. L5845 is an additional feature and/or function that does not describe a 
complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin 
system. L5973 describes an endoskeletal device with integrated energy storage and release foot and 
microprocessor ankle system. The integrated microprocessor is programmable along with sensors to optimize 
plantar and dorsiflexion angles for stance and swing phase. L5973 includes foot cover, power source(s) and 
charger. You can find this rule in the Local Coverage Determination and Article for Lower Limb Prostheses, 
L33787 and A52496. 
 
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 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 say that providers should report the most appropriate ICD-10 code that adequately describes the 
patients medical condition at the time of transport as the primary diagnosis. In addition, a secondary diagnosis, 
from ICD-10 Code Group 3 below, must be reported. Code Group 3 includes the following: Z74.01 (Bed 
confinement status), Z74.3 (Need for continuous supervision), Z78.1 (Physical restraint status) and Z99.89 
(Dependence on other enabling machines and devices). You can find this information in the Centers for 
Medicare and Medicaid Services, Local Coverage Article (LCA): Billing and Coding: Ambulance Services 
(Ground Ambulance) (A54574). 
 
The rules say that in a case where the beneficiary was pronounced dead after the ambulance is 
called/dispatched but before the ambulance arrives at the scene: Payment may be made for a basic life support 
(BLS) service if a ground vehicle is dispatched. Neither mileage nor a rural adjustment would be paid. The 
blended rate amount will otherwise apply. Providers or suppliers report the A0428 (BLS) non-emergency or 
A0429 (BLS) emergency transport Healthcare Common Procedure Coding System (HCPCS) code if an 
emergency response and modifier QL (Patient pronounced dead after ambulance called) in HCPCS/Rates 
instead of the origin and destination modifier for ground vehicles. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 15, Section 30.2. 
 
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 reconstructive surgery is performed on abnormal structures of the body caused by congenital 
defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to 
improve function but may also be done to approximate a normal appearance. 
 
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance 
and self-esteem. Cosmetic surgery performed purely for the purpose of enhancing one's appearance is not 
eligible for coverage. Cosmetic surgery performed to treat psychiatric or emotional problems is not covered. 
You can find this rule at Local Coverage Determination (LCD) L35163: Plastic Surgery (eff. 10/1/19). 
 
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. 
 
Medicare guidance says the following data elements are required to submit a claim under home health PPS. For 
billing of home health claims not under an HH plan of care (not under HH PPS), see Section 90. Home health 
services under a plan of care are paid based on a 30-day period of care. HHAs submit an NOA at the beginning 
of an admission and then submit one claim for each 30-day period of care. Claims submitted before an NOA 
has been received for the beneficiary will be returned to the provider. Statement Covers Period Required - The 
beginning and ending dates of the period covered by this claim. For continuous care periods, the through date 
must be 29 days after the From date for a 30-day period of care In cases where the beneficiary has been 
discharged or transferred within the period, HHAs will report the date of discharge in accordance with internal 
discharge procedures as the through date. If the beneficiary has died, the HHA reports the date of death in the 
through date. The HHA may submit claims for payment immediately after the claim through date. It is not 
required to hold claims until the end of the period of care unless the beneficiary continues under care. 
Admission/Start of Care Date Required - The HHA enters a date of admission matching the From date on the 
first period of care in an admission. On subsequent periods of care, the HHA continues to submit the admission 
date reported on the first period of care. You can find this guidance in the Medicare Claims Processing Manual 
Chapter 10, sec 40.2 - HH PPS Claims. 
 
Medicare guidance says the A/B MACs (A) must provide a listing of the required data elements, including a 
brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the distinction 
between submissions which are not considered claims, but which are returned to provider (RTP) and 
submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted 
as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected 
on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected 
and re-submitted. You can find this guidance in the Medicare Claims Processing Manual Chapter 1, sec 
70.2.3.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, 50.2, 50.5, and 110.3. 
 
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 Plan 
contract says that covered drugs include: Drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
You can find this information in Chapter 4 on page 4-38 of the Plan's 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 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 active diagnoses are intended to code diseases that have a direct relationship to the residents 
current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or 
risk of death. One of the important functions of the Minimum Data Set (MDS) assessment is to generate an 
updated, accurate picture of the residents current health status. You can find this rule in the Centers for 
Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 
3. 
 
The rules say that a mechanically altered diet is a diet specifically prepared to alter the texture or consistency of 
food in order to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened 
liquids. You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Appendix A-11. 
 
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 disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) 
are non-covered devices because they do not meet the Medicare definition of durable medical equipment. You 
can find this information in Medicare's Local Coverage Article for External Infusion Pumps - Policy Article 
(A52507). 
 
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 while electric nerve stimulation has been employed to control chronic intractable pain for some 
time, its use in the treatment of motor function disorders, such as multiple sclerosis, is a recent innovation, and 
the medical effectiveness of such therapy has not been verified by scientifically controlled studies. 
 
Indications and Limitations of Coverage 
 
Where electric nerve stimulation is employed to treat motor function disorders, no reimbursement may be made 
for the stimulator or for the services related to its implantation since this treatment cannot be considered 
reasonable and necessary. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 160.2. 
 
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 the ESIs must be performed under computed tomography (CT) or fluoroscopy image 
guidance with contrast unless the patient has a documented contrast allergy or pregnancy where ultrasound 
guidance without contrast may be considered. You can find this information in Local Coverage Determination 
(LCD): Epidural Steroid Injections for Pain Management (L39015). 
 
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.