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 diagnostic procedures should be performed with the intent that if successful, a RFA 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
A second diagnostic facet procedure is considered medically reasonable and 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. You can find this rule at 
Local Coverage Determination (LCD) L34892: Facet Joint Interventions for Pain Management (eff. 4/25/21). 
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 home oxygen therapy is reasonable and necessary only if all of the following conditions are 
met: 
1. The treating practitioner has determined that the beneficiary has a severe lung disease or hypoxia-
related symptoms that might be expected to improve with oxygen therapy, and 
2. The beneficiary's blood gas study meets the criteria stated below, and 
3. The qualifying blood gas study was performed by a treating practitioner or by a qualified provider or 
supplier of laboratory services, and 
4. The qualifying blood gas study was obtained under the following conditions:  
 If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test 
must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge 
date, or 
 If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported 
test must be performed while the beneficiary is in a chronic stable state  i.e., not during a 
period of acute illness or an exacerbation of their underlying disease, and 
5. Alternative treatment measures have been tried or considered and deemed clinically ineffective. 
In this policy, the term blood gas study refers to either an oximetry test or an arterial blood gas test. You can 
find this rule at Local Coverage Determination (LCD) L33797: Oxygen and Oxygen Equipment (eff. 8/2/20). 
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 non-elastic binder for an extremity (A4465) is an example of a wound care item which is 
non-covered under the surgical dressing benefit because it does not meet the statutory definition of a dressing. 
You can find this rule in Local Coverage Article: Surgical Dressings - Policy Article (A54563). 
 
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 panel constitutes a single procedural service, so one code must be submitted for the panel. 
This rule can be found in Medicare National Coverage Determination: Next Generation Sequencing (NGS) 
90.2. 
 
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 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 15 to 16 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 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 for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
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 Physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. If more than one evaluation and management (face-to-face) service is 
provided on the same day to the same patient by the same physician or more than one physician in the same 
specialty in the same group, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. You can find this rule in Medicare Claims 
Processing Manual, Chapter 12, Section 30.6.5. 
 
The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other 
supplier claims submitted to a MAC or carrier is a claim or claim line that exactly matches another claim or 
claim line with respect to the following elements: Medicare beneficiary identifier, provider Number, from date 
of service, through date of service, type of service, procedure Code, place of Service, and billed amount. You 
can find this information in the Medicare Claims Processing Manual, Chapter 1 Section 120.2. 
 
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 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 you must see a hearing provider in the Plans hearing network in order for hearing aids 
to be covered. You can find this information on page 86 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. 
 
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. The Plan 
contract also says that eye refractions and dilation are covered during a routine exam by a contracted routine 
vision provider. You can find this information on pages 106-109 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 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 (CMS), Medicare National Correct Coding Initiative Policy 
Manual for Medicare Services, Chapter I(A). 
 
The rules say that modifiers are used to identify therapy services whether or not financial limitations are in 
effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy 
modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of 
applicable therapy codes except as noted in Section 20 of this chapter. Consult Section 20 for the list of codes 
to which modifiers must be applied. These modifiers do not allow a provider to deliver services that they are 
not qualified and recognized by Medicare to perform. The claim must include a modifier to distinguish the 
discipline of the plan of care under which the service is delivered. Modifiers GN, GO, and GP refer only to 
services provided under plans of care for physical therapy, occupational therapy, and speech-language 
pathology services. They should never be used with codes that are not on the list of applicable therapy services. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.1. 
  
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 state that total knee replacement (TKR) surgery medically necessary when one or more of the 
following criteria are met:  
 
Advanced joint disease demonstrated by:  
 
-    Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance 
imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint 
subluxation, joint space narrowing, avascular necrosis);  
-    Pain or functional disability from injury due to trauma or arthritis of the joint; and 
-    If appropriate, a history of unsuccessful conservative therapy (non-surgical medical management) that is 
clearly addressed in the pre procedure medical record. (If conservative therapy is not appropriate, the medical 
record must clearly document why such approach is not reasonable);  
-    Failure of a previous osteotomy;  
-    Distal femur fracture;  
-    Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues;  
-    failure of previous unicompartmental knee replacement 
-    avascular necrosis of the knee; or 
-    proximal tibia fracture 
 
Non-surgical medical management is usually, but not always, implanted prior to scheduling total joint surgery. 
Non-surgical treatment is clinically appropriate for the patients current episode of care typically includes one 
or more of the following: 
 
-    anti-inflammatory medications, analgesics 
-    flexibility and muscle strengthening exercises 
-    supervised physical therapy (ADLs diminished despite completing a plan of care), 
-    assistive device use,  
-    weight reduction as appropriate, or 
-    therapeutic injections to the knee as appropriate 
 
In some circumstances, for example, if the patient has bone-on-bone articulation, severe deformity, or pain and 
significant disabling interference with ADLs, the surgeon may determine that nonsurgical medical management 
would be ineffective of counterproductive, and that the best treatment option, after explaining the risks, is surgical. If medical management is deemed inappropriate the medical record should indicate the rationale for 
and circumstances under which this is the case.  
 
You can find this information in the Local Coverage Determination (LCD): Total Joint Arthroplasty (L33456). 
 
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 another type of pre-symptom MLR, it is implanted subcutaneously in a patients upper left 
chest and may remain implanted for many months. An ILR is used when syncope is thought to be cardiac-
related, but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom MLR. 
 
You can find this in the National Coverage Determination (NCD) for Electrocardiographic Services (20.15). 
 
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 repeat treatments are considered medically necessary for patients being treated for 
osteoarthritis of the knee, who meet both of the following criteria: 
 Significant improvement in knee pain and known improvement in functional capacity resulted from the 
previous series of injections which has been documented in the record; and 
 At least six (6) months have elapsed since the last injection in the series. 
 
You can find this rule in the Local Coverage Article for Billing and Coding: Intraarticular Knee Injections of 
Hyaluronan, A56157.  
 
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 physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. Physicians in the same group practice but who are in different specialties 
may bill and be paid without regard to their membership in the same group. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 12, Section 30.6.5. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the only provider types who are eligible to furnish outpatient mental health services to 
Medicare patients are as follows: physicians, clinical psychologists, clinical social workers, clinical nurse 
specialists, nurse practitioners, physician assistants, certified nurse-midwives, independently practicing 
psychologists, and certified registered nurse anesthetists. You can find this rule at Centers for Medicare and 
Medicaid Services, MedLean Matters booklet entitled Medicare Mental Health, MLN 1986542. 
 
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 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 a Medicare plan may not pay for services given by a physician or other practitioner who has 
opted out of Medicare. This rule does not apply to emergency or urgently needed services. A Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 
6, Section 60.2. 
 
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 members of the Plan can receive care from either an in-network or out-of-network provider. 
While enrollees can get care from an out-of-network provider, the provider must be eligible to participate in 
Medicare. Except for emergency care, the Plan cannot pay a provider that is not eligible to participate in 
Medicare. If you go to a provider that is not eligible to participate in Medicare, you will be responsible for the 
full cost of the services you receive. You can find this information in Chapter 3 on pages 51 to 52 of the Plans 
2021 Evidence of Coverage.