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 for claims with dates of service on or after January 1, 2023, a non-adjunctive continuous 
glucose monitor (CGM) must be billed with code E2103. Code E2103 describes a non-adjunctive CGM that 
meets the requirements of the durable medical equipment (DME) benefit. To be eligible for Medicare 
reimbursement, all CGM devices billed as E2103 must have received coding verification review by the Pricing, 
Data Analysis and Coding (PDAC) contractor and be listed on the Product Classification List (PCL) for 
Healthcare Common Procedure Coding System (HCPCS) code E2103. You can find this information in the 
Local Coverage Article: Glucose Monitor - Policy Article (A52464). 
 
The rules say that a Freestyle Libre 3 is not specified as a product that may be billed using code E2103. You 
can find this information in the Product Classification List (PCL) on the Pricing Data Analysis, and Coding 
(PDAC) contractor website 
https://www4.palmettogba.com/pdac_dmecs/searchProductClassificationResults.do?manufacturer=&codeDecis
ion=k0554&productName=&modelNumber=&classification=). 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Palmetto GBA Molecular Diagnostic Program manual, 
Chapter 1, Section 1.4. 
 
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 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 page 20 of the Plan's 2023 Schedule of Cost Sharing.
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 epidural steroid injection (ESI) will be considered medically reasonable and necessary when 
the following requirements are met: 
 
o History, physical examination, and concordant radiological image-based diagnostic testing that supports 
one of the following: 
   - Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis OR 
   - Post-laminectomy syndrome, OR 
   - Acute herpes zoster associated pain. 
AND 
o Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality 
of life or function. An objective pain scale or functional assessment must be performed at baseline (prior to 
interventions). The same scale must be used at each follow-up for assessment of response. 
AND 
o Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes 
zoster refractory to conservative management where a four (4) week wait is not required. 
 
You can find this information in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L36920). 
 
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 a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1852) are covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). They are also covered for a beneficiary who is ambulatory and has knee instability. 
Knee instability must be documented by examination of the beneficiary and objective description of joint laxity 
(e.g., varus/valgus instability, anterior/posterior Drawer test). These claims will be denied as not reasonable and 
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied 
if only pain or a subjective description of joint instability is documented. You can find this rule in the Local 
Coverage Determination (LCD) - Knee Orthoses (L33318). 
 
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. 
 
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 also says that the Plan covers inpatient hospital care. Prior authorization may be required 
and is the responsibility of the enrollee's provider. You can find this information on pages 92 to 95 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 state that the replacement of items due to irreparable wear takes into consideration the Reasonable 
Useful Lifetime (RUL) of the item. The RUL of durable medical equipment (DME) is determined through 
program instructions. In the absence of program instructions, carriers may determine the RUL, but in no case 
can it be less than five years. If the item has been in continuous use by the beneficiary on either rental or 
purchase basis for its RUL, the beneficiary may elect to obtain a replacement. 
  
You can find this information in the Local Coverage Article (LCA) Standard Documentation Requirements for 
All Claim Submitted to DME MACs (A552426).  
 
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 physical therapy, speech-language pathology services, and occupational therapy are bundled 
into the SNFs global per diem payment for a residents covered Part A stay. They are also subject to the SNF 
Part B consolidated billing requirement (for services furnished to SNF residents during noncovered stays) 
and must be billed by the SNF alone for its Part B residents on a 22x type of bill. You can find this rule in the 
Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing Manual, Chapter 6, 
Section 20.5. 
 
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 payment may be made for a one-time ultrasound screening for abdominal aortic aneurysm 
(AAA) for beneficiaries who meet the following criteria: 
 
(i) receives a referral for such an ultrasound screening from the beneficiarys attending physician, physician 
assistant, nurse practitioner or clinical nurse specialist; 
(ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered 
ultrasound diagnostic services; 
(iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and 
(iv) is included in at least one of the following risk categories-  
 
(I) has a family history of abdominal aortic aneurysm; 
(II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or 
(III) is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by 
the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and 
Human Services, through the national coverage determination process. 
 
You can find this information in Local Coverage Article: Billing and Coding: Once in a Lifetime Abdominal 
Aortic Aneurysm (AAA) Screening Article (A55071). 
 
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 Medicare Part B coverage is available for outpatient Opioid Treatment Program (OTP) 
services provided by hospitals, Critical Access Hospitals (CAHs), and Free-Standing Opioid Treatment 
Program facilities. This rule is found in Medicare Claims Processing Manual, Chapter 39, Section 30.6. 
 
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 initial evaluation is always included in the allowance for a minor surgical procedure. You 
can find this rule in the Center for Medicare Services (CMS) Internet-Only Manual Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
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 a pneumatic compression device coded with E0675 is used in the treatment of peripheral 
arterial disease. There is insufficient evidence to demonstrate that reimbursement is justified. Claims for E0675 
will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination 
(LCD) - Pneumatic Compression Devices (L33829) - Effective January 1, 2020. 
 
The rules say that accessories (E0673) are eligible for reimbursement only when appropriate related base 
device (E0675) meets the applicable coverage criteria. If the base device is not covered, related accessories are 
not eligible for reimbursement. Claims for related items will be denied as not reasonable and necessary. You 
can find this rule in the Local Coverage Determination (LCD) - Pneumatic Compression Devices (L33829) - 
Effective January 1, 2020. 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 Medicare Part B coverage is available for outpatient Opioid Treatment Program (OTP) 
services provided by hospitals, Critical Access Hospitals (CAHs), and Free-Standing Opioid Treatment 
Program facilities. You can find this information in the Medicare Claims Processing Manual, Chapter 39, 
Section 50. 
 
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 Section 424.57(c)(12) requires suppliers, as part of their standards to be met for enrollment 
and participating, to maintain proof of delivery documentation in their files. In certain instances, compliance 
with proof of delivery may be required as a condition of payment, and must be available. For such items, if the 
supplier does not have appropriate proof of delivery documentation within the prescribed timeframes, 
associated claims will be denied, and overpayments recouped. You can find this rule in the Medicare Program 
Integrity Manual, Chapter 5, Section 5.8. 
 
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 state that molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Approved tests will be 
reimbursed consistent with the effective date of the coverage determination. You can find this rule in the Local 
Coverage Determination (LCD): MolDX: Molecular Diagnostic Tests (MDT) (L35025). 
 
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 molecular diagnostic laboratory tests must undergo an application and technical assessment 
process through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. Labs must submit a 
comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and 
reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the 
Medicare reasonable and necessary requirement. This rule requires that all tests that are approved by this 
process be assigned a unique test identifier from the DEXTM Diagnostics Exchange. Only approved tests will be 
reimbursed consistent with the effective date of the coverage determination. This unique identifier must be 
reported on the claim. You can find this rule in the Palmetto GBA Molecular Diagnostic Testing Program 
manual, Chapter 1, Section 1.4. 
 
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 pages 32 to 33 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 plans 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 prior authorization is required for radiation therapy. You can find this information on page 
122 of the 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 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). 
 
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.