Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare & Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 72 one-way trips per calendar year. You can find this information on pages 119 and 120 of the 
Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
The rules say that the Medicare contractors could strengthen their program safeguards for ensuring that 
Medicare claims for drug testing services for beneficiaries with substance use disorders comply with Medicare 
requirements. We identified three weaknesses in the established program safeguards for preventing and 
detecting improper payments for drug testing services and promoting provider compliance with Medicare 
requirements. Specifically, the Medicare contractors did not have: 
 
1. clear and consistent requirements or guidance for laboratories to use when determining the number of drug 
classes to bill for definitive drug testing services, 
2. procedures for identifying or limiting the frequency of drug testing services (e.g., the number of drug tests 
performed per year) for each beneficiary across all Medicare jurisdictions, and 
3. consistent requirements in their LCDs or any procedures for identifying claims for direct-to-definitive drug 
testing 
 
You can find this rule in the U.S Department of Health & Human Services, Office of Inspector General - 
Report in Brief from June 2021, Report No. A-09-20-03017 - Opportunities Exist for CMS and Its Medicare 
Contractors To Strengthen Program Safeguards To Prevent and Detect Improper Payments for Drug Testing 
Services. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that definitive drug testing may be reported with Healthcare Common Procedure Coding System 
(HCPCS) codes G0480-G0483. These codes differ based on the number of drug classes including metabolites 
tested. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct 
Coding Initiative Policy Manual for Medicare Services, Chapter XII, Section C(11). 
 
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 page(s) 42-43 of the Plan's 
2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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 20% coinsurance for Medicare Part B prescription drugs.  You can find 
this information on page(s) 66-67 of the Plan's 2023 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 a second diagnostic facet procedure is considered medically necessary to confirm validity 
of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances 
that necessitate an exception to the two-week duration may be considered on an individual basis and must be 
clearly documented in the medical record. 
 
A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet ALL the following criteria: 
 
1) The patient meets the criteria for the first diagnostic procedure; AND 
2) After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% 
relief of primary (index) pain (with the duration of relief being consistent with the agent used) 
 
You can find this information in the Local Coverage Determination (LCD) L35936: Facet Joint Interventions 
for Pain Management. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that when a comparative imaging study is performed to assess potential complications or 
completeness of a procedure (e.g., post-reduction, post-intubation, post-catheter placement, etc.), the 
professional component of the CPT code for the post-procedure imaging study is not separately payable and 
shall not be reported. The technical component of the CPT code for the post-procedure imaging study may be 
reported. You can find this rule in the National Correct Coding Initiative Policy Manual 2023, Chapter IX 
Radiology Services CPT Codes 70000-79999; page 5; C. Non-interventional Diagnostic Imaging #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 say that Medicare pays for care in an SNF when all of the following four factors are met: 
 
1. The patient requires skilled nursing or skilled rehabilitation services; 
2. The patient requires these services daily; 
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 
4. The services are reasonable and necessary for the treatment of the patients illness or injury, or the services 
must be needed to establish a safe and effective maintenance program or to prevent the enrollee's condition 
from getting worse.  
 
You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare & Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.   
 
The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need 
ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of 
daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, 
and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also 
custodial care services. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $275 copayment for outpatient diagnostic tests and therapeutic services 
and supplies.  You can find this information on page(s) 62 to 63 of the Plan's 2023 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 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 & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
The rules say that treatment with testosterone is medically reasonable and necessary when prescribed for: 
- Symptomatic hypogonadism (congenital or acquired) due to a disorder of the testicles, pituitary gland, or 
brain 
- Delayed male puberty 
- Gender dysphoria in a member who is able to make an informed decision to engage in hormone therapy 
You can find these rules in Local Coverage Determination (LCD) Treatment of Males with Low 
Testostgerone (L39086). 
 
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.

Medicare does not pay for low vision aids. You can find this rule at 42 CFR Section 411.15(b).

Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42
CFR Section 411.15(c).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The 2022 Plan contract says the Plan reimburses up to $100 every year for non-Medicare covered prescription
eyewear. The enrollee is responsible for any amount above the $100 eyewear coverage limit. You can see this
on page 120 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 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 & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 65-66, and 99 of the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that carriers may not pay for the technical component (TC) of radiology services furnished to 
hospital patients. Payment for physicians' radiological services to the hospital, e.g., administrative or 
supervisory services, and for provider services needed to produce the radiology service, is made by the payer to 
the hospital as a provider service. You can find this information in the Centers for Medicare & Medicaid 
Services, Internet-Only Manual, Publication Number 100-04, Medicare Claims Processing Manual, Chapter 13, 
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.
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 thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint 
(medial branch (MB)) nerves are considered medically reasonable and necessary for patients who meet all the 
following criteria: 
1.  
a.  Initial thermal RFA: 
i.  After the patient has had at least 2 medically reasonable and necessary 
diagnostic MBBs, with each 1 providing a consistent minimum of 80% sustained 
relief of primary (index) pain (with the duration of relief being consistent with 
the agent used); AND 
ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically 
reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least 6 months or at least 50% consistent 
improvement in the ability to perform previously painful movements and ADLs 
as compared to baseline measurement using the same scale 
Frequency Limitation: For each covered spinal region no more than 2 radiofrequency sessions will be 
reimbursed per rolling 12 months. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L38765: Facet Joint Interventions 
for Pain Management. 
 
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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
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. The Coding Policy Manual also explains 
what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code 
pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items 
for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct 
Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to 
include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit 
file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the 
code pair to bypass the edit. You can find this rule in the Centers for Medicare & 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.