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 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 services related to non-covered services or drugs are not covered (e.g., administration 
services). You can find this rule in the Local Coverage Article for the Billing and Coding of Approved Drugs 
and Biologicals; Includes Cancer Chemotherapeutic Agents, A53049. 
 
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. 
 
The rules say that OnabotulinumtoxinA is indicated for the treatment of overactive bladder (OAB) with 
symptoms of urge urinary incontinence, urgency, and frequency, in adults and patients five years of age and 
older who have an inadequate response to or are intolerant of an anticholinergic medication. You can find this 
rule in the Local Coverage Determination (LCD) for Botulinum Toxins, L33646. 
 
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 either a non-heated (E0561) or heated (E0562) humidifier is covered and paid separately 
when ordered by the treating practitioner for use with a covered E0470 or E0471 respiratory assistive devices 
(RAD). You can find this information in 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 the quantity of ostomy supplies needed by a beneficiary is determined primarily by the type 
of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will 
be variation according to individual beneficiary need and their needs may vary over time. The table below lists 
the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity 
needed for a particular beneficiary may be more or less than the amount listed depending on the factors that 
affect the frequency of barrier and pouch change. 
 
The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in 
the beneficiarys medical record. If adequate documentation is not provided when requested, the excess 
quantities will be denied as not reasonable and necessary. 
 
USUAL MAXIMUM QUANTITY OF SUPPLIES: 
 
A5063 60 
 
When a liquid barrier is necessary, either liquid or spray (A4369) or individual wipes or swabs (A5120) are 
appropriate. The use of both is not reasonable and necessary. 
 
Beneficiaries with continent stomas may use the following means to prevent/manage drainage: stoma cap 
(A5055), stoma plug (A5081), stoma absorptive cover (A5083) or gauze pads (A6216). No more than one of 
these types of supply would be reasonable and necessary on a given day. 
 
Beneficiaries with urinary ostomies may use either a bag (A4357) or bottle (A5102) for drainage at night. It is 
not reasonable and necessary to have both. 
 
You can find these rules in the Local Coverage Determination (LCD) Ostomy Supplies L33828. 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 (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
2. The services require the skills or direct supervision of a therapist,  
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. 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 220.2. 
 
The local Medicare Administrative Contractor has published its interpretation of the various outpatient therapy 
rules which provide more specific criteria for certain services. You can find this information in the Local 
Coverage Determination (LCD): L33631 
 
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 Respiratory (RP) and Pneumonia (PNP) Panels will only be covered when targeted testing is 
not appropriate AND according to the following additional criteria:  
 For immune-competent patients, at least 1 of the following must apply:  
 Testing is ordered by a clinician specialist in Infectious Diseases or Pulmonology for a patient 
with severe and established underlying respiratory pathology (i.e., severe asthma, chronic 
obstructive pulmonary disease (COPD), cystic fibrosis, pulmonary fibrosis, radiation therapy to 
the lung) AND treatment with antibiotics may be indicated according to established guidelines. 
Specific examples that do NOT meet coverage criteria according to established guidelines 
include the following:  
 Asthma exacerbations without the additional presence of either fever and purulent 
sputum or radiographic evidence of pneumonia
2
   Uncomplicated community acquired pneumonia (CAP)  
 The patient is seriously or critically ill or at imminent risk of becoming seriously or critically ill 
(as defined by the American Hospital Association's "General Guide for the Release of 
Information on the Condition of Patients") as a result of a presumed respiratory infection AND 
the patient is being treated in an appropriate critical care facility. 
You can find the rules in Local Coverage Determination (LCD) MolDX: Molecular Syndromic Panels for 
Infectious Disease Pathogen Identification Testing L38988. 
 
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 raised toilet seats are not covered because they are considered hygienic equipment that is not 
primarily medical in nature. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.1. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 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.  
 
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 hospital beds are covered only with a physicians prescription and sufficient documentation 
in the patients medical records to establish medical necessity for a hospital bed due to one of the following 
reasons: 
 
1. The patients condition requires positioning of the body; e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or   
 
2. The patients condition requires special attachments that cannot be fixed and used on an ordinary bed.  
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 280.7. 
 
A heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for 
a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 
pounds. You can find this information in the Local Coverage Determination (LCD) for Hospital Beds and 
Accessories (L33820). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that effective January 1, 2002, sacral nerve stimulation is covered for the treatment of urinary 
urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both 
a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent 
implantation in appropriate candidates. Both the test and the permanent implantation are covered. The 
following limitations for coverage apply to all three indications: 
- Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or 
surgical corrective therapy) and be an appropriate surgical candidate such that implantation with 
anesthesia can occur. 
- Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes 
with peripheral nerve involvement) which are associated with secondary manifestations of the above 
three indications are excluded. 
- Patient must have had a successful test stimulation in order to support subsequent implantation. Before 
a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement 
through test stimulation. Improvement is measured through voiding diaries. 
- Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical 
results of the implant procedure can be properly evaluated. 
 
You can find these rules in National Coverage Determination (NCD) Sacral Nerve Stimulation for Urinary 
Incontinence (230.18). 
 
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 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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that beginning January 1, 2021, CMS will establish a new add-on payment of $25 as identified by 
HCPCS code U0005. As required by the HCPCS code U0005 descriptor, this add-on payment may be billed 
with either HCPCS code U0003 or HCPCS code U0004 when the applicable test is completed within 2 
calendar days of the specimen being collected. You can find this ruling in the Centers for Medicare and 
Medicaid Services, Ruling Number CMS-2020-1-R2. 
 
The rules say that the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. 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. 
 
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).  
 
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 there is a $525 deductible which applies to certain items and services. The Plan 
deductible applies to the lab services. You can find this information on page 48 of the Plan's 2023 Evidence of 
Coverage (EOC).   
 
The Plan contract also says that enrollees must pay a $10 copayment per day, per provider, for Medicare-
covered lab services. You can find this information on pages 92 to 93 of the Plan's 2023 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 injection of a carpal tunnel or tarsal tunnel is indicated for the patient with a mild case of 
these syndromes, with or without a trial of other conservative measures, such as oral non-steroidal anti-
inflammatory drugs (NSAIDs) or orthoses. Injection into tendon sheaths, ligaments, tendon origins or 
insertions, ganglion cysts, neuromas or other areas described by this policy may be indicated to relieve pain or 
dysfunction resulting from inflammation or other pathological changes. Proper use of this modality with local 
anesthetics and/or steroids should be short-term, as part of an overall management plan including diagnostic 
evaluation, in order to clearly identify and properly treat the primary cause. In some circumstances after 
diagnosis has been confirmed, injection of a sclerosing or neurolytic agent may be appropriate for longer-term 
management. 
 
Medical necessity for injections of more than two sites at one session or for frequent or repeated injections is 
questionable. Such injections are likely to result in a request for medical records which must evidence careful 
justification of necessity. "Dry needling" of ganglion cysts, ligaments, neuromas, tendon sheaths and their 
origins/insertions are non-covered procedures. You can find these rules in Local Coverage Determination 
(LCD) Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes, and Morton's Neuroma (L34218). 
 
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 durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. 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(C). 
 
The rules say that replacement refers to the provision of an identical or nearly identical item. Situations 
involving the provision of a different item because of a change in medical condition are not addressed in this 
section. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or  
irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire,  
flood). A physicians order and/or new Certificate of Medical Necessity (CMN), when required, is needed  
to reaffirm the medical necessity of the item. 
 
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event  
cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the  
reasonable useful lifetime of the equipment. If the item of equipment has been in continuous use by the  
patient on either a rental or purchase basis for the equipments useful lifetime, the beneficiary may elect to  
obtain a new piece of equipment. Replacement may be reimbursed when a new physician order and/or new  
CMN, when required, is needed to reaffirm the medical necessity of the item.  
 
Charges for the replacement of oxygen equipment, items that require frequent and substantial servicing or  
inexpensive or routinely purchased items which are being rented are not covered. 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 110.2(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.
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 an SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable 
and necessary. You can find this information in the Local Coverage Determination (LCD): Sacroiliac Joint 
Injections and Procedures (L39462). 
 
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.