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 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 clinical laboratory tests include some services described as anatomic pathology services 
in CPT (i.e., certain cervical, vaginal, or peripheral blood smears). The CPT code 85060 is used only when a 
physician interprets an abnormal peripheral blood smear for a hospital inpatient or a hospital outpatient, and the 
hospital is responsible for the technical component. When an independent laboratory bills a physician 
interpretation of an abnormal peripheral blood smear, the service is considered a complete or global service, 
and is not billed under the CPT code 85060. A physician interpretation of an abnormal peripheral blood smear performed by an independent laboratory is considered a routine part of the ordered hematology service (i.e., 
those tests that include a different white blood count). You can find this rule in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-104, Chapter 16, Section 80.2. 
 
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 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 $95 copayment for other diagnostic procedures and tests, including a nerve study and a 20% coinsurance for Medicare Part B prescription drugs. You can find this information on pages 52-54 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 state that certain ICD-10-CM codes listed are covered for code 87086. 
Any ICD-10-CM code not listed in either of the ICD-10-CM covered section do not support medically 
necessity. You can find this rule in the Medicare National Coverage Determinations (NCD) for Coding Policy 
Manual and Change Report (ICD-10-CM), April 2023. 
 
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 pay for an inpatient rehabilitation facility (IRF) admission when the services are reasonable and medically necessary.

The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.
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 a 10% coinsurance for Medicare Part B prescription drugs up to a $300 out of pocket maximum. You can find this information on pages A1-40 of the Plan's 2022 Annual Notice of Changes.
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 special supplemental benefit for the chronically ill (SSBCI) is a supplemental benefit that has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health or overall function of the enrollee. The rules define a chronically ill enrollee as one who has one or more comorbid and medically complex chronic conditions that meet all of the following: 1. Is life threatening or significantly limits the overall health or function of the enrollee; 2. Has a high risk of hospitalization or other adverse health outcomes; and 3. Requires intensive care coordination. The rules also say that the Plan must have written policies for determining enrollee eligibility and must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 42 CFR 422.102.
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 if you have been diagnosed by a qualified provider with certain chronic conditions and you meet certain criteria, you may be eligible for additional benefits. You can find this information on page 104 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 say that Medicare will pay for an inpatient rehabilitation facility (IRF) admission when the services 
are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary 
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one 
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must 
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. 
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at 
least five days per week. The patient does not need to be expected to achieve complete independence in self-
care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a 
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 
412.622. 
 
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 indications for approval for an ambulatory electroencephalogram (EEG) include: 
 
 Inconclusive EEGs; 
 Experiencing episodic events where epilepsy is suspected but the history, examination, and 
routine EEG do not resolve the diagnostic uncertainties; 
 Patients with confirmed epilepsy who are experiencing suspected non-epileptic events or for 
classification of seizure type (only ictal recordings can reliably be used to classify seizure type 
(or types) which is important in selecting appropriate anti-epileptic drug therapy; 
 Differentiating between neurological and cardiac related problems; 
 Adjusting anti-epileptic medication levels; 
 Localizing seizure focus for enhanced patient management; 
 Identifying and medicating absence seizures; 
 For suspected seizures of sleep disturbances; 
 Seizures which are precipitated by naturally occurring cyclic events or environmental stimuli 
which are not reproducible in the hospital or clinic setting. 
 
You can find these rules in Local Coverage Determination (LCD) EEG  Ambulatory Monitoring L33399.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the 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. 
 
The rules state that the date of service (DOS) for laboratory tests must be the date the specimen was collected. 
One exception is testing on stored specimens which only changes the DOS if it would be medically 
inappropriate to have collected the sample other than during the hospital procedure for which the patient was 
admitted. There are other exceptions for chemotherapy sensitivity testing on live tissue and advanced 
diagnostic laboratory/molecular pathology tests. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
16, Section 40.8. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 stress fracture. 
 spondylosis. 
 infection (e.g., discitis). 
 tumor (e.g., osteoid osteoma). 
 analyze blood flow to an organ, as in the case of myocardial viability. 
 differentiate ischemic heart disease from dilated cardiomyopathy. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 220.12. 
 
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 a combinatorial pharmacogenomics (PGx) test is a type of multi-gene panel that requires a 
proprietary algorithm to evaluate pharmacokinetic or pharmacodynamic relationships resulting in drug 
recommendations or warnings. When more than two codes from this list are submitted for the same beneficiary 
on the same date of service, the claims processing system will deny every code submitted after the first two 
services. However, if a lab runs more than two distinct procedural services from this list on a single date of 
service, then the lab must use the -59 modifier with each additional service billed as an attestation that it is a 
distinct procedural service. Billing the -59 modifier may result in a request for medical records. You can find 
this rule in the Local Coverage Determination and Article for Pharmacogenomics Testing, L39073 and 
A58812. 
 
The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the lab shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one 
unit of service. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be 
reported for the procedure. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare 
National Correct Coding Initiative Manual, Chapter X(F). 
 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that the 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.

The rules state that a standard written order (SWO) is required prior to claim submission for all options, accessories, and/or supplies that are separately billed in addition to the base. This SWO obtained prior to claim submission, may be prepared by someone other than a treating practitioner. If someone other than a treating practitioner prepares the SWO for separately billed options, accessories, and/or supplies, a treating practitioner must review and sign the order.

The rules also say that prior to or at the time of delivery of a power operated vehicle (POV) or power wheelchair (PWC), the supplier or practitioner must perform an on-site evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request.

You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 43 to 47 of the Plans 
2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary for osteoporotic conditions when ALL of the following criteria are 
met: 

- Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic Vertebral Compression Fracture 
(VCF) (T1 - L5) based on symptom onset, and documented by recent (within 30 days) advanced imaging and 
- The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
visual Analog Scale [VAS] pain score greater than or equal to 8) or is non-hospitalized with moderate to severe 
pain (NRS or VAS greater than or equal to 5) despite optimal non-surgical management (NSM) with one of the 
following: 
   - Worsening pain or 
   - Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or more of the following 
are present: 
      - Progression of vertebral body height loss 
      - Greater than 25% vertebral body height reduction 
      - Kyphotic deformity 
      - Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) greater 
than 17) 
      - Steroid-induced fractures 
      - Reinforcement or stabilization of vertebral body prior to surgery 
 
Malignant Vertebral Fractures 
Osteolytic vertebral metastasis or myeloma with severe back pain related to a destruction of the vertebral body, 
not involving the major part of the cortical bone. 
1. Painful osteolytic metastasis 
2. Multiple myeloma with painful vertebral body involvement 
 
Traumatic Compression Fractures 
Trauma, even minor falls, can produce a spine fracture. Many of these injuries will never require surgery, but 
major fractures can result in serious long-term problems unless treated promptly and properly. These severe injuries frequently result in spinal instability, with a high risk of spinal cord injury and pain, which can produce 
a spine fracture. Coverage of PVA is reasonable and necessary for the following traumatic conditions. 
1. Stable and/or unstable burst fractures 
2. Wedge compression fractures 
3. Fracture-dislocations that occur following auto accidents or falls from height 
 
You can find this information in the Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38213). 
 
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.