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 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 you are covered by both Medicare and Medicaid. Medicare is the Federal health
insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and
people with end-stage renal disease (kidney failure). Medicaid is a joint Federal and state government program
that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies
depending on the state and the type of Medicaid you have. Some people with Medicaid get help paying for
their Medicare premiums and other costs. Other people also get coverage for additional services and drugs that
are not covered by Medicare. You can see this on page 11 of the Plans 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
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 29-31 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 pays for up to 100 days of skilled care in a SNF in each benefit period. A benefit 
period begins upon admission to a hospital or SNF and ends after 60 days in a row without the patient receiving 
hospital or skilled SNF services. You can find this rule in the Social Security Act, Section 1862(a)(18), at 42 
CFR Sections 409.60(a) and (b) and Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Section 
10.4. 
 
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. The Plan 
contract also says that SNF services are only covered for 100 days. You can find this information in Chapter 4 
on page 96 of the Plans 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 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 20% coinsurance for durable medical equipment. You can find this 
information on page 63 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 wireless capsule endoscopy (WCE) is indicated for the diagnosis of occult gastrointestinal 
bleeding (i.e., likely involving the small intestine), the site of which has not previously been identified by any 
of the following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging or 
radiological procedures. 
    WCE is limited to those patients who have undergone upper gastrointestinal (GI) endoscopy and 
colonoscopy and these tests have failed to reveal a source of bleeding. Medicare would not expect to see a 
WCE provided if upper and lower endoscopy has not previously been performed. Documentation in the 
medical record must indicate that the beneficiary has suspected GI blood loss with or without anemia. 
Appropriate differential diagnoses for the evaluation of such bleeding include: 
        Angiodysplasia 
        Neoplasm 
        Iron deficiency anemia, which is unexplained after upper and lower endoscopy 
        Zollinger-Ellison syndrome 
        Tuberculosis 
        Vasculitis 
        Radiation enteritis 
        Meckels diverticulum 
        Jejunal diverticula 
        Chronic mesenteric ischemia 
    Other indications include the management of celiac disease (e.g., surveillance for small-intestinal cancer) 
and of Crohns disease (that is, either Crohns disease is suspected, but not diagnosed, or colonic involvement 
of Crohns disease is known, but it is necessary to determine whether there is also involvement of the small 
bowel). In addition, WCE is indicated where an indeterminate type of colitis exists, but where a more specific 
diagnosis is being sought via small bowel evaluation. 
    Esophageal capsule endoscopy may be used in the evaluation of esophageal varices in patients with portal 
hypertension, as an alternative to upper GI endoscopy. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Wireless Capsule 
Endoscopy (L35089). 
 
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 state that when treatment for complications requires a return trip to the operating room, physicians 
must bill the code that describes the procedure(s) performed during the return trip. If no such code exists, use 
the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for the original 
surgery is not used except when the identical procedure is repeated. In addition to the code, physicians use 
modifier -78 for these return trips (return to the operating room for a related procedure during a postoperative 
period.) 
 
Modifier -79 is used to report an unrelated procedure by the same physician during a postoperative period. 
The physician may need to indicate that the performance of a procedure or service during a postoperative 
period was unrelated to the original procedure.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 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 plans may specify brands and manufacturers as preferred and charge lower cost-sharing for 
the preferred brands or may limit the durable medical equipment (DME) to only those preferred brands and 
manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred 
brands). You can find this information in the Medicare Managed Care Manual Chapter 4, Section 10.12.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan says that they only cover blood glucose monitors and test strips from Accu-Chek manufactured by 
Roche, or Trividia products. You can find this information on page 64 of the Plans 2022 Evidence of 
Coverage.  
 
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 Plan 
contract says they have a link that will take you to a list of Part B Drugs that may be subject to step therapy. 
You can find this information on page 25 of the Plan's 2022 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 state that the following indications are covered for implanted permanent single chamber or dual 
chamber cardiac pacemakers: 
1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block. 
 
You can find these rules in National Coverage Determination (NCD) Cardiac Pacemakers: Single Chamber and 
Dual Chamber Permanent Cardiac Pacemakers (20.8.3). 
 
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 an FDG PET scan is considered reasonable and necessary in patients with a recent 
diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for 
both AD and FTD, and who have been evaluated for specific alternate neurodegenerative diseases or other 
causative factors, but the cause of the clinical symptoms remains uncertain or only in the context of an 
approved clinical trial that contains patient safeguards and protections to ensure proper administration, use and 
evaluation of the FDG PET scan. You can find this information in Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) 
Manual Section 220.6.13. 
 
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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
 
The MA plan provides all categories of DME covered under original Medicare Part B; 
The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
The MA plans contracted suppliers provide access to all preferred DME brands; 
During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-
day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the EOC and ANOC and on its website; and 
The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-16, Medicare Managed Care Manual, Chapter 4, 10.12.2. 
 
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 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 PGx tests are indicated when medications are being considered for use (or already being 
administered) that are medically necessary, appropriate, and approved for use in the patients condition and are 
known to have a gene(s)-drug interaction that has been demonstrated to be clinically actionable as defined by 
the FDA (PGx information required for safe drug administration) or Clinical Pharmacogenetic Implementation 
Consortium (CPIC) guidelines (category A and B). 
The selection of the medications in question must be derived from clinical factors/necessity rather than from a 
PGx test. Once the putative therapeutic agents are selected, and those agents are known to have gene-drug 
interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of 
that test is necessary for the physicians decision-making process regarding safely administering or dosing the 
drug. 
PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular 
diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to 
make a preliminary drug selection, PGx testing is not considered reasonable and necessary. You can find the 
rules in Local Coverage Determination (LCD) MolDX: Pharmacogenomics Testing L38394. 
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 reimbursement for oxygen equipment is limited to 36 monthly rental payments. Payment 
for accessories, delivery, back-up equipment, maintenance, and repairs is included in the rental allowance. 
Payment for oxygen contents is included in the allowance for stationary equipment. 
 
A new 36-month rental period can begin only in the following situations: 
 
   - Specific incident of damage beyond repair or the item is stolen or lost 
   - Break-in-need for at least 60 days plus the days remaining in the month of discontinuation and new medical 
necessity is established 
 
A new 36-month rental period does not start in the following situations: 
 
   - Replacing equipment due to malfunction, wear and tear, routine maintenance, repair 
   - Providing different equipment based on a treating practitioner order or beneficiary request for an upgrade 
   - Break-in-need less than 60 days plus the days remaining in the month of discontinuation 
   - Break-in-billing 
   - Changing suppliers 
 
There is no further payment for oxygen equipment during the 5-year reasonable useful lifetime (RUL) of the 
equipment after 36 rental payments have been made. If use of portable equipment begins after the use of 
stationary equipment begins, payment for the portable equipment can continue after payment for the stationary 
equipment ends until 36 rental payments have been made for the portable equipment. 
 
The supplier who provided the equipment during the 36th rental month is required to continue to provide the 
equipment, accessories, contents, maintenance, and repair of the oxygen equipment during the 5 year 
reasonable useful lifetime of the equipment. 
 
Rules for providing different equipment/modalities are the same in months 37-60 as they are in the initial 36 
months. 
 
A new 36-month rental period can begin only in the following situation: 
 
    - There is a specific incident of damage beyond repair or the item is stolen or lost  
A new 36-month rental period does not start in the following situations: 
 
   - Replacing equipment due to malfunction, wear and tear, routine maintenance, repair 
   - Providing different equipment based on a treating practitioner order or beneficiary request for an upgrade 
   - Break-in-need  
   - Break-in-billing  
   - Changing suppliers 
 
You can find this information in the Local Coverage Article Oxygen and Oxygen Equipment - Policy Article 
(A52514). 
 
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 revenue code must be billed in sections FL42 and FL43 of the claim form. You can find 
this rule in the Center for Medicare Services (CMS) Publication 100-04, Medicare Claims Processing Manual, 
Chapter 25, Section 75. 
 
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 fluid circulating cold pad with pump will be denied as not reasonable and necessary. You 
can find this rule in the Local Coverage Determination (LCD) for Cold Therapy (L33735). 
 
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.