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.  
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
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. The Plan 
contract says that enrollees must pay a $196 copayment per day for days 21 to 100 for skilled nursing facility 
(SNF) care. You can find this information on page 71 of the Plan's 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that percutaneous vertebral augmentation (PVA) (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with both the following: 
1. Inclusion criteria (all are required): 
a. 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 
b. Symptomatic (one of the following): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale 
(VAS) pain score of 8 or more) 
ii. Non-hospitalized with moderate to severe pain (NRS or VAS of 5 or more) despite 
optimal non-surgical management (NSM)(one of the following): 
1. Worsening pain 
2. Stable to improved pain (but NRS or VAS still 5 or more) (with 2 or more of the 
following): 
A. Progression of vertebral body height loss 
B. Greater than 25% vertebral body height reduction 
C. Kyphotic deformity 
D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) greater than 17 
c. Continuum of care (Both)  
i. All patients presenting with VCF should be referred for evaluation of bone mineral 
density (BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis 
prevention/treatment program. 
2. Exclusion criteria (Can have none of the following):   
a.  Absolute contraindication 
i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
ii. Osteomyelitis, discitis, active systemic or surgical site infection 
iii. Pregnancy b. Relative contraindication 
i. Greater than three vertebral fractures per procedure 
ii. Allergy to bone cement or opacification agents 
iii. Uncorrected coagulopathy 
iv. Spinal instability 
v. Myelopathy from the fracture 
vi. Neurologic deficit 
vii. Neural impingement 
viii. Fracture retropulsion/canal compromise 
 
You can find these rules in Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L33569). 
 
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 treatment for lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) will 
be considered reasonable and necessary once per lifetime in patients with: 
1. All of the following indications: 
a. Age 80 
b. Prostate volume of 30-150 cc transrectal ultrasound (TRUS) 
c. Persistent moderate to severe symptoms despite maximal medical management including all of 
the following: 
i. International Prostate Symptom Score (IPSS) 12 
ii. Maximum urinary flow rate (Qmax) of 15 mL/s (voided volume greater than 125 cc) 
iii. Failure, contraindication or intolerance to at least three months of conventional medical 
therapy for LUTS/BPH 
2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary. 
 
Transurethral waterjet ablation of the prostate is not considered reasonable and necessary for patients with the 
following: 
1. Body mass index  42kg/m2 
2. Known or suspected prostate cancer or a prostate specific antigen (PSA) >10 ng/mL unless the patient 
has had a negative prostate biopsy within the last 6 months. 
3. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum 
4. Active urinary tract or systemic infection 
5. Treatment for chronic prostatitis 
6. Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 
7. Damaged external urinary sphincter 
8. Known allergy to device materials 
9. Inability to safely stop anticoagulants or antiplatelet agents preoperatively. 
 
You can find this information in Local Coverage Determination (LCD): Transurethral Waterjet Ablation of the 
Prostate (L38682). 
 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 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 72 one-way trips per year. Each one-way trip must not exceed 50 miles of driving distance. You 
can find this information in Chapter 4 on pages 99 to 100 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 say that plans can restrict members to using contract providers except for emergency care (including 
ambulance services), out-of-area urgently needed care, post-stabilization care, and pre-approved care. You can 
find this rule at 42 CFR Section 422.112(a)(9). 
 
The rules say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a 
contract provider or a non-contract provider. Emergency care ends when the patient is stabilized.  
 
Post-stabilization care is care that is administered to maintain, improve, or resolve the enrollee's stabilized 
condition. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is 
obtained from a non-contract provider, approval is required from the plan. However, the requirement for pre-
approval does not apply if: 
 
1. The Plan does not respond to a request for pre-approval within one hour, 
 
2. The Plan cannot be contacted, or 
 
3. The Plan representative and the treating physician cannot reach an agreement concerning the enrollee's care 
and a plan physician is not available for consultation. 
You can find this rule at 42 CFR Section 422.113(c). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules. 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 pages 31 to 38 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 the Medicare approved amount for surgical procedures with a 90-day global surgery 
indicator includes payment for items such as dressing changes; local incisional care; removal of operative pack; 
removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints when related to the 
surgery and when furnished by the physician who performs the surgery. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, 40.1(A). 
 
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 effective for claims with dates of service on and after December 23, 2009, the Centers for 
Medicare and Medicaid Services (CMS) determines that the evidence is adequate to conclude that Outpatient 
Intravenous Insulin Treatment (OIVIT) does not improve health outcomes in Medicare beneficiaries. 
Therefore, CMS determines that OIVIT is not reasonable and necessary for any indication under section 
1862(a)(1)(A) of the Social Security Act. Services comprising an Outpatient Intravenous Insulin Therapy 
regimen are nationally non-covered under Medicare. This rule is found in National Coverage Determination 
(NCD): Outpatient Intravenous Insulin Treatment (40.7). 
 
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 also say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) require a written order/prescription from the treating practitioner. The supplier must keep the order 
and proof of delivery documentation on file. All services that do not have appropriate proof of delivery will be 
denied. The supplier should also obtain as much documentation from the patients medical record as they 
determine they need to assure themselves that coverage criteria for an item have been met. If the information in 
the patients medical record does not adequately support the medical necessity for the item, the supplier is 
liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of 
possible denial has been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 
and 5.10. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare 
Managed Care Manual, Chapter 1, Section 20.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 37 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 high frequency chest wall oscillation devices (HFCWODs) are covered when they are 
medically necessary for enrollees who have: 
 cystic fibrosis; or 
  
   bronchiectasis that has been confirmed by CT scan; or  
 one of these neuromuscular diseases: post-polio, acid maltase deficiency, anterior horn cell diseases, 
multiple sclerosis, quadriplegia, hereditary muscular dystrophy, myotonic disorders, other myopathies, or 
paralysis of the diaphragm.  
 
Medical records must show failure of standard treatments to clear secretions. The rules also say that chronic 
bronchitis and chronic obstructive pulmonary disease (COPD) do not meet criteria for coverage when there is 
no diagnosis of bronchiectasis. You can find these rules in the Medicare Local Coverage Determination (LCD) 
L33785, High Frequency Chest Wall Oscillation Devices. This LCD is effective for services provided on or 
after July 1, 2016. 
 
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 certain data elements are required for home health services. Any claim with incomplete, 
missing, or invalid information for all of these elements may be returned as unprocessable. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 1, Section 80.3.1. 
 
The rules say that in the case of home health services furnished on or after January 1, 2019, the claim should 
contain the code for the county (or equivalent area) in which the home health service was furnished.  The 
National Uniform Billing Committee created a new code to meet this requirement. This new value code 85 is 
effective on January 1, 2019, and is defined as "County Where Service is Rendered" and providers should 
report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence 
where the home health service is delivered. You can find this rule in the MLN Matters MM10782 - CR10782 - 
Effective January 1, 2019. 
 
The rules say that where required by law or regulation, the provider should report the Federal Information 
Processing Standards (FIPS) State and County Code of the place of residence where the home health service is 
delivered. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 10, 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 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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. 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. 
 
The rules state that an "order" is a communication from the treating physician/practitioner requesting that a 
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit 
Policy Manual, Chapter 15, Section 80.6.1. 
 
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 state that pharmacogenomics (PGx) tests must demonstrate analytical validity, clinical validity, and 
clinical utility to be considered reasonable and necessary for coverage. This is demonstrated through a required 
technical assessment of the test. PGx tests are considered germline tests and must adhere to other relevant 
germline testing policies published by this contractor.  
 
PGx tests are indicated when medications are being considered for use (or already being administered) that are 
medically necessary, appropriate, and approved for use in the patients condition and are known to have a 
gene(s)-drug interaction that has been demonstrated to be clinically actionable as defined by the FDA (PGx 
information required for safe drug administration) or Clinical Pharmacogenetic Implementation Consortium 
(CPIC) guidelines (category A and B). 
 
The selection of the medications in question must be derived from clinical factors/necessity rather than from a 
PGx test. Once the putative therapeutic agents are selected, and those agents are known to have gene-drug 
interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of 
that test is necessary for the physicians decision-making process regarding safely administering or dosing the 
drug. 
 
PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular 
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to 
make a preliminary drug selection, PGx testing is not considered reasonable and necessary. 
 
You can find this information in Local Coverage Determination (LCD): MolDX: Pharmacogenomics Testing 
(L38394). 
 
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.