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 no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 10, Section 10.1.2. 
 
The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The term 
room confined means that the patients condition is such that leaving the room is medically contraindicated. 
The accessibility of bathroom facilities generally would not be a factor in this determination. However, 
confinement of a patient to a home in a case where there are no toilet facilities in the home may be equated to 
room confinement. You can find this information in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, Medical National Coverage Determinations Manual, Chapter 1, Section 
280.1. 
 
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 Nursing care provided by or under the supervision of a registered professional nurse is 
covered. However, the services of a private-duty nurse or other private-duty attendant are not covered. Private-
duty nurses or private-duty attendants are registered professional nurses, licensed practical nurses, or any other 
trained attendant whose services ordinarily are rendered to, and restricted to, a particular patient by 
arrangement between the patient and the private-duty nurse or attendant. You can find this in the Centers for 
Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 8, Section 50.1. 
 
The rules also say that Medicare covers home health services, including part-time or intermittent skilled 
nursing care. The term "part-time or intermittent" for purposes of coverage under 1861(m) of the Act means 
skilled nursing and home health aide services furnished any number of days per week as long as they are 
furnished (combined) less than 8 hours each day and 28 or fewer hours each week. You can find this in the 
Medicare Claims Processing Manual, Chapter 7, Section 40. 
 
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 private duty nursing services as a supplemental (extra) benefit. This benefit pays for 
up to $5,000 for private duty nursing services per year. You can find this information on page 119 of the Plans 
2021 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 tests evaluated through the application process and/or technical assessment will be reviewed 
to answer the following questions: 
 
1. Is the test performed in the absence of clinical signs and symptoms of disease? 
2. Will the test results provide the clinician with information that will improve patient outcomes and/or change 
physician care and treatment of the patient? 
3. Will the test results confirm a diagnosis or known information? 
4. Is the test performed to determine risk for developing a disease or condition? 
5. Will risk assessment change management of the patient? 
6. Is there a diagnosis specific indication to perform the test? 
7. Is the test performed to measure the quality of a process or for Quality Control/Quality Assurance (QC/QA), 
i.e., a test to ensure a tissue specimen matches the patient? 
 
You can find this rule in the Local Coverage Determination (LCD) - MolDX: Molecular Diagnostic Tests 
(MDT) (L35160) - Effective November 1, 2019. 
 
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 guidance says to receive payment for covered Medicare items or services from either Medicare (in 
the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or 
supplier must be enrolled in the Medicare program. You can find this guidance in Medicare Code of Federal 
Regulations 42 CFR Section 424.505. You can find this document on the Centers for Medicare & Medicaid 
Services' website, www.cms.gov. 
 
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 health 
plan contract says that while you can get your care from an out-of-network provider, the provider must be 
eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to 
participate in Medicare. If you go to provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. Check with your provider before receiving services to 
confirm that they are eligible to participate in Medicare. You can find this information in Chapter 3 on page 44 
of the plan's 2021 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 local Medicare coverage of biomarkers must be predicated upon three fundamental 
principles: 
 
1. First, there must be an underlying performance of acceptable, high-quality analytical validity for all such 
laboratory testing. As a result, the laboratory shall have available upon request: 
 
-Analytical and clinical validation reports for Clinical Laboratory Improvement Amendments (CLIA), 
including the test description, intended use, and indications for testing. 
-If applicable, all formal, written minutes and correspondences (including any Q & A and supporting 
documentation) with the New York State Department of Health (NYSDOH) or the United States (U.S.) Food 
and Drug Administration (FDA). 
-Most recent inspection results (including recommendations) or scheduled inspection(s) from CLIA, College of 
American Pathologists (CAP), or NYSDOH, as applicable. 
 
2. Second, there must be an appreciation of evidence-in-transition where new biomarkers should be brought on-
line in harmonization with their proven clinical validity/utility (CVU). Although analytical validity is an 
equally important metric, it remains more outside of a payer's purview to conduct such detailed evaluations. 
Therefore, in the absence of a standard CVU referee process (e.g., although FDA labeling of biomarkers can be 
a helpful adjunct, it may not always be relevant), the key imperative is for medical necessity to be reflected by 
the clear articulation of a particular biomarker niche. 
3. Third, there must be a recognized decision impact of such biomarkers by the clinical community. In other 
words, there must be acceptance/uptake of specific testing into patient management. It should be taken into 
account that to reach the medical necessity threshold, such acceptance should be based on the strongest 
evidence available, ideally from along the spectrum of high-quality masked, randomized controlled clinical 
trials, and much less preferably from lower levels of evidence, which are predicated upon expert opinion only 
without primary study data. 
 
You can find this rule in the Local Coverage Determination (LCD) - Biomarkers Overview (L35062) - 
Effective October 1, 2015. 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. This exclusion includes all devices that use one or more lenses to 
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. 
This rule does not apply to:  
 
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after 
each cataract surgery with insertion of an IOL; and  
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with 
an IOL.  
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 Plan contract says that the Plan covers items and services in accordance with Medicare rules. Your 
contract says that routine eyewear that is not covered by Medicare is covered under a supplemental benefit. 
This provides up to a $250 allowance per year for eyewear. You can find this on pages 79-80 of the Plan's 2021 
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 CPAP Machine (E0601) is considered a capped rental item, meaning it must be rented and 
cannot be purchased. This information is found in The Durable Medical Equipment, Prosthetics, Orthotics, and 
Supplies April 2021 Fee Schedule. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes only the 
codes listed in the benefit chart. Code D9995 is not listed You can find this information on pages 116 to 149 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 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). 
 
Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) payment is contingent on the 
requirement that IRFs complete a patient assessment upon admission and discharge for Medicare patients. The 
August 7, 2001, Final Rule, and subsequent final rules contain detailed information regarding the assessment 
schedule for the patient assessment instrument (PAI) with respect to transmission requirements, encoding dates, 
and other pertinent information. Further, there is an item-by-item guide, which specifies detailed instructions 
regarding the manner in which each item on the assessment instrument needs to be completed.  
 
Effective with cost reporting periods beginning on or after January 1, 2002, IRFs are required to report billing 
data with a new revenue code and a Health Insurance PPS (HIPPS) Rate Code on the ASC X12 837 
institutional claim or, in rare cases, on the Form CMS-1450 for all Part A inpatient claims (Type of Bill 11X) 
to their A/B MACs (A). The new revenue code, 0024, is used in conjunction with the HIPPS Rate Code to 
identify the CMG payment classification for the beneficiary. In addition to all entries previously required on a 
Part A claim, the following additional instructions must be followed to accurately price and pay a claim under 
the IRF PPS. These claims must be submitted on Type of Bill 11X. The last four digits of the provider number 
for rehabilitation hospitals is from 3025 to 3099, and for rehabilitation distinct part units the third digit will be a 
T if the unit is located in an acute care hospital or an R if the unit is located in a CAH.  
 
The Revenue code must contain revenue code 0024. This code indicates that this claim is being paid under the 
PPS. This revenue code can appear on a claim only once. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.3. 
 
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 will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit does not list 
guided tissue regeneration, bone grafts or  tooth extractions as covered services. You can find this information 
on pages 4-57 to 4-62 of the Plans 2021 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). 
 
The rules also say that as a general rule, the date of service for a clinical laboratory test or the technical 
component of physician pathology service must be the date the specimen was collected. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 16, Section 40.8. 
 
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 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 and 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 60 one-way trips to Plan-approved locations every year. You can find this information on pages 4-
83 to 4-84 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 that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, 
fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(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. The Plan 
contract also says that routine hearing services must be received from a participating provider in order to be 
covered by the Plan. You can find this information on page 88 of the Plan's 2021 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 thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
 
        Initial thermal RFA: 
            After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with 
each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of 
relief being consistent with the agent used)  AND 
            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 six (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 two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L38773. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.