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 ventilators may be covered when they are medically necessary for patients who have 
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive 
pulmonary disease (COPD). You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure (BiPAP) device is 
made based upon the specifics of each persons medical condition. There must be enough detailed information 
in the medical record to justify the treatment selected. Ventilators fall under the Frequent and Substantial 
Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for devices used to 
deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated by the device. 
This means that products currently classified as Healthcare Common Procedure Coding System (HCPCS) code 
E0465, E0466, or E0467 when used to provide continuous positive airway pressure (CPAP) or BiPAP (with or 
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS 
payment category and will be denied as not reasonable and necessary. You can find this rule in the Local 
Coverage Determination (LCD): Respiratory Assist Devices (L33800). 
 
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 under home health (HH) prospective payment system (PPS), home health agencies (HHAs) 
may discharge beneficiaries before the period of care has closed if all treatment goals of the plan of care have 
been met. Cases may occur in which a home health agency (HHA) has discharged a beneficiary during a period 
of care, but the beneficiary is readmitted to the same agency in the same 30 days. Since no portion of the period 
can be paid twice, the first payment must be pro-rated to reflect the shortened period (see 10.1.15). A new 
admission period can be opened by the HHA. Medicare systems will allow this in cases where the CMS 
certification number (CCN) on the new NOA matches the CCN on the prior period. The next period of care 
will begin the date the first service is supplied under readmission (setting a new 30-day clock). 
 
Note that beneficiaries do not have to be discharged within the period because of admissions to other types of 
health care providers (i.e., hospitals, skilled nursing facilities), but HHAs may choose to discharge in such 
cases. If an agency chooses not to discharge and the patient returns to the agency in the same 30-day period, the 
same period of care continues. However, if an agency chooses to discharge, based on an expectation that the 
beneficiary will not return, the agency should recognize that if the beneficiary does return to them in the same 
period, the discharge is not recognized for Medicare payment purposes. All the HH services provided in the 
complete period of care, both before and after the inpatient stay, should be billed on one claim. When 
discharging, full payment would still be made unless the beneficiary received more home care later in the same 
period. 
 
Discharge is not required if the beneficiary has an inpatient stay that spans the end of the first 30-day period of 
care in a 60-day certification period. The HHA should submit the claim for the period following the discharge 
as if the 30-day periods were contiguous  submit a From date of day 31, even though it falls during the 
inpatient stay and the first visit date that occurs after the hospital discharge. Medicare systems will allow the 
HH claim to overlap the inpatient claim for dates in which there are no HH visits. 
 You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.14. 
 
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 for the purposes of Medicare reimbursement, repairs are not synonymous with replacements. 
Repairs (parts and labor) of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items 
are performed on the base item. The replacement of parts or components that make up the base item is 
considered to be a repair. Conversely, the furnishing of new separately payable accessories that were not part of 
the initial base item is considered to be replacement, which is addressed in the section below. 
 
Replacement of a beneficiary owned DMEPOS item typically involves providing an identical or nearly 
identical item. 
 
REPAIRS 
 
The definition of a repair is found in the Medicare Benefit Policy Manual (Centers for Medicare and Medicaid 
Services (CMS) Pub. 100-02), Chapter 15, Section 110.2.A. That section generally defines repair as to fix or 
mend and to put the item back in good condition after damage or wear. 
 
Repairs to items which a beneficiary owns are covered when necessary to make the items serviceable. 
However, routine periodic maintenance, such as testing, cleaning, regulating, and checking is not covered. 
 
Medicare does not separately reimburse for repairs of: 
Items in the frequent and substantial servicing payment category; or, 
Oxygen equipment; or, 
Items in the capped rental payment category during the capped rental period; or, 
Items covered under a manufacturers or suppliers warranty; or, 
Previously denied items. 
A new certificate of medical necessity (CMN) and/or treating practitioners order is not needed for repairs. 
 
In the case of repairs to a beneficiary-owned DMEPOS item, if Medicare paid for the base item initially, 
medical necessity for the base item has been established. With respect to Medicare reimbursement for the 
repair, there are two documentation requirements: The treating practitioner must document that the DMEPOS item being repaired continues to be reasonable and 
necessary (see Continued Medical Need section above); and, 
Either the treating practitioner or the supplier must document that the repair itself is reasonable and necessary. 
The supplier must maintain detailed records describing the need for and nature of all repairs including a 
detailed explanation of the justification for any component or part replaced as well as the labor time to restore 
the item to its functionality. 
 
You can find these rules in the Local Coverage Article Standard Documentation Requirements for All Claims 
Submitted to durable medical equipment (DME) Medicare Administrative Contracts (MACs) A55426. 
 
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 rules say that certain individuals and entities frequently attempt to enroll in Medicare 
but are not eligible to do so. If the Medicare contractor receives an enrollment application from the individual 
or entity, the contractor shall deny the application. Licensed Practical Nurse (LPN) is among the provider types 
that are not eligible to enroll in Medicare. You can find this rule in Medicare Program Integrity Manual 
Chapter 10, Section 10.2.8. 
 
The rules say that to receive payment for covered items or services from either Medicare or a Medicare 
beneficiary, a provider or supplier must be enrolled in the Medicare program. You can find this rule in 42 Code 
of Federal Regulations (CFR) Section 424.505. 
 
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 codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as 
principal diagnosis when a related definitive diagnosis has been established. Codes that describe symptoms and 
signs are acceptable for reporting purposes when a related definitive diagnosis has not been established 
(confirmed) by the provider. You can find this rule in the 2022 international classification of diseases, tenth 
edition, clinical modification (ICD-10-CM) Diagnosis Codebook, Section I and II. 
 
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 current molecular diagnostic tests that identify individuals with upper gastrointestinal 
metaplasia, dysplasia, and neoplasia are non-covered. You can find this information in Local Coverage 
Determination (LCD): MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, 
Dysplasia, and Neoplasia (L39262). 
 
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 home health agencies must bill with the correct Type of Bill code. Home health services are 
billed with Type of Bill 032x.  The last digit indicates the sequence of this bill in this particular period of care. 
Except for replacement or voided/cancelled claims, the fourth digit must be a 9 to indicate that it is the final 
claim. You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only 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 biofeedback therapy is covered under Medicare only when it is reasonable and necessary for 
the individual patient for muscle re-education of specific muscle groups or for treating pathological muscle 
abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments (heat, 
cold, massage, exercise, support) have not been successful. This therapy is not covered for treatment of 
ordinary muscle tension states or for psychosomatic conditions. You can find this rule in the National Coverage 
Determination (NCD) - Biofeedback Therapy (30.1). 
 
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 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 definitive drug testing is indicated when: 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical 
history. 
3. This test may also be used, when the coverage criteria of the policy are met AND there is no 
presumptive test available, locally and/or commercially, as may be the case for certain synthetic or 
semi-synthetic opioids. 
You can find this rule in Local Coverage Determination (LCD) Drug Testing L34645. 
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 for outpatient encounters for diagnostic tests that have been interpreted by a physician, and 
the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in 
the interpretation. Do not code related signs and symptoms as additional diagnoses. Symptoms, signs and 
abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) may be reported in addition to a 
related definitive diagnosis when the sign or symptom is not routinely associated with complex syndromes. The 
definitive diagnosis should be sequenced before the symptom code. You can find this information in the 
Centers for Medicare and Medicaid Services, ICD-10-CM Official Guidelines for Coding and Reporting FY 
2023, Sections IV.K and I.C.18. 
 
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 stress testing with cardiac imaging will be considered medically reasonable and necessary 
for patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained 
angina equivalent symptoms, and a physical inability to perform a maximum exercise workload, or new or 
previously unrecognized uninterpretable electrocardiogram (ECG). You can find this information in the Local 
Coverage Determination (LCD): Cardiology Non-emergent Outpatient Stress Testing (L38396). 
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 certain items of durable medical equipment can only be rented, and not purchased. The 
Durable Medical Equipment Coding System (DMECS) states that K0813 - power wheelchair, group 1 
standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds  is 
considered a capped rental item. This item may only be rented. You can find this rule in the Pricing, Data 
Analysis and Coding (PDAC) DMECS. 
 
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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules say that Medicare coverage of cardiovascular screening blood tests 
(tests for the early detection of cardiovascular disease or abnormalities associated with an elevated risk for 
that disease) effective with services performed on or after January 1, 2005. MMA requires coverage of 
tests for cholesterol and other lipid or triglycerides levels for this purpose. 
You can find this rule in the 42 CFR Section 410.17. 
 
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 a Type I polysomnography (PSG) is covered when used to aid the diagnosis of obstructive 
sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed 
attended in a sleep lab facility. Type I devices are capable of recordings of all of the physiologic parameters 
and signals defined for PSG. The recording is furnished in a sleep laboratory facility in which a technologist is 
physically present to supervise the recording during sleep time and has the ability to intervene if needed. 
Minimal requirements include recording of electroencephalogram (EEG), electrooculography (EOG), chin 
electromyography (EMG), anterior tibialis EMG, electrocardiogram (ECG), airflow, respiratory effort and 
oxygen saturation. Body position must be documented or objectively measured. Trained personnel must be in 
constant attendance and able to intervene. You can find this information in the Local Coverage Determination 
(LCD) for Polysomnography and Sleep Testing (L33405). 
 
The rules also say that for a diagnosis of OSA to be made, the following criteria must be met:  
 
A. Prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating physician to assess the 
patient for OSA which must include, at a minimum, the following: 
 
    Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, 
choking or gasping during sleep, morning headaches; and, 
    Epworth Sleepiness Scale; and, 
    Physical examination that documents body mass index, neck circumference and a focused cardiopulmonary 
and upper airway system evaluation. 
 
B. The patient has a covered sleep test that meets either of the following criteria:  
 
    The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 
events per hour with a minimum of 30 events; or, 
    The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 
10 events and documentation of:  
        Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
        Hypertension, ischemic heart disease, or history of stroke 
 
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 a list of 
covered preventive and comprehensive dental benefits and covered procedure codes. You can find this 
information on page 41 of the Plans 2023 Evidence of Coverage (EOC) and in the 2023 Comprehensive 
Dental Plan Information Guide.