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 also 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. Medicare 
rules say that providers must report services correctly. Providers must report services with the appropriate 
procedure code. 
 
 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, 3.3.2.1. 
 
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 home health agencies may not submit the claim until after all services are provided for the 
period, and the physician has signed the plan of care, and any subsequent verbal order. 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 10.1.10.4 - Claim Submission and Processing. 
 
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 reasonable useful lifetime of durable medical equipment is determined through program 
instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful 
lifetime of equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on 
when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is 
not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, 
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary 
equipment owned by the beneficiary. 
 
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 copayment per day for diagnostic tests, including an EKG. You can 
find this information on page 101 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that if you receive other services during an office visit, the cost share may apply 
according to the benefit specific category. You can find this information on page 107 of the Plans 2022 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 starting in calendar year 2021, a payment reduction will apply when the HHA does not submit 
the RAP within 5 calendar days from the start of care date ("admission date" and "from date" on the claim will 
match the start of care date) for the first 30-day period of care in a 60-day certification period, and within 5 
calendar days of the "from date" for the second 30-day period of care in the 60-day certification period. The 
payment reduction will be equal to a 1/30th reduction to the 30-day period payment amount for each day from 
the home health start of care date/admission date, or "from date" for subsequent 30-day periods, until the date 
the HHA submits the RAP. You can find this information in the Centers for Medicare and Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Transmittal 10403, Change 
Request 11855. 
 
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 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 VCF (T1 - L5) based on symptom onset, and 
documented by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) 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 
Continuum of Care 
All patients presenting with vertebral compression fractures (VCF) should be referred for evaluation of bone 
mineral density and osteoporosis education for subsequent treatment as indicated and instructed to take part in 
an osteoporosis prevention/treatment program. 
Exclusion criteria for any patient considered for percutaneous vertebroplasty or vertebral augmentation: 

1. Absolute contraindication 
A. Current back pain is not primarily due to the identified acute VCF(s). 
B. Osteomyelitis, discitis, or active systemic infection 
2. Relative contraindication 
A. Greater than three vertebral fractures per procedure B. Allergy to bone cement or opacification agents 
C. Uncorrected coagulopathy 
D. Spinal instability 
E. Myelopathy from the fracture 
F. Neurologic deficit 
G. Neural impingement 
H. Fracture retropulsion/canal compromise 
I. Pregnancy 

You can find these rules in the Local Coverage Determination (LCD) for 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.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
intraoral - periapical each additional radiographic image (D0230) but is limited to one (1) procedure code per 
calendar year. You can find this information on page 84 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract also says that this benefit includes specific dental procedures listed. Consultation - diagnostic 
service (D9310) is not listed as covered. You can find this information on pages 83-85 of the Plans 2022 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 patients exhibiting hypoxemia are defined using the clinical criteria below: 
Group I: 
 
    An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88%, taken at rest, 
breathing room air; or 
    An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88%, taken during sleep 
for a patient who demonstrates an arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or 
above 89%, while awake; or a greater than normal fall in oxygen level during sleep (a decrease in arterial PO2 
more than 10 mm Hg, or decrease in arterial oxygen saturation more than 5%) associated with symptoms or 
signs reasonably attributable to hypoxemia (e.g., impairment of cognitive processes and nocturnal restlessness 
or insomnia). In either of these cases, coverage is provided only for use of oxygen during sleep, and then only 
one type of unit will be covered. Portable oxygen, therefore, would not be covered in this situation; or, 
    An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, taken during 
exercise [defined as either the functional performance of the patient or a formal exercise test], for a patient who 
demonstrates an arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, during 
the day while at rest. In this case, supplemental oxygen is provided for during exercise if the use of oxygen 
improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. 
 
The MAC may determine reasonable and necessary coverage of oxygen therapy and oxygen equipment in the 
home for patients who are not described in subsection B or precluded by subsection C of this NCD. Initial 
coverage for patients with other conditions may be limited to the shorter of 90 days or the number of days 
included in the practitioner prescription at MAC discretion. Oxygen coverage may be renewed if deemed 
medically necessary by the MAC. 
 
You can find this information in the National Coverage Determination (NCD) Home Use of Oxygen 240.2. 
 
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 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 3-4 of the Plans 2022 
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 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(s) 1-6 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 Providers performing validity testing on urine specimens used for drug testing shall not 
separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, 
creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not 
separately billed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National 
Correct Coding Initiative Policy Manual for Medicare Services, Chapter X, Section E.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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
limited oral evaluation but is limited to 2 visits per year. The re-cement or re-bond fixed retainer and surgical 
extractions are not covered by the Plan's dental benefits. You can find this information on pages 69 to 71 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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to one set every five calendar years for complete or partial dentures. 
You can find this information in Chapter 4 on pages 77 to 78 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 may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 91-92 of the Plan's 2023 Evidence of Coverage