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 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 50 one-way non-emergency trips to Plan-approved locations within the Plan service area. You can find 
this information in Chapter 4 on pages 72 to 73 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 state that panels with greater than 5 respiratory pathogens performed in the Part B outpatient setting 
are considered not medically necessary. 
 
A respiratory pathogen panel test is a single service with a single unit of service (UOS=1). A respiratory 
pathogen panel test must not be unbundled and billed as individual components regardless of the fact that the 
panel reports multiple individual pathogens and/or targets. You can find this information in Local Coverage 
Determination (LCD): Respiratory Pathogen Panel Testing (L38916) and the related Local Coverage Article: 
Billing and Coding: Respiratory Pathogen Panel Testing (A28575). 
 
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 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.  
 
Licensed mental health counselors frequently attempt to enroll in Medicare but are not eligible to do so; no 
statute permits them to bill Medicare. 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 
10.2.8  
 
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 60 one-way trips. You can find this information on pages 92-93 in 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 providers 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 effective for claims with dates of service July 1, 2007 and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE 
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the 
Web at the following address 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
The rules say that edit 62 applies when an outpatient claim is submitted with a code that is not recognized by 
OPPS. Services with a status indicator of B always return edit 62. An alternate code for the same service may 
be available. The disposition for this edit is "return to provider" (RTP), which means that there is one or more 
edits present which cause the entire claim to be denied and returned to the provider. A claim returned to the 
provider means that the provider can resubmit the claim once the problems are corrected. You can find this 
information in the Integrated OCE Centers for Medicare and Medicaid Services (CMS) Specifications V23.3 
Effective October 1, 2022. 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 sleep studies and polysomnography (PSG) refer to the continuous and simultaneous 
monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more 
hours with physician review, interpretation and report. The studies are performed to diagnose a variety of sleep 
disorders and to evaluate a patient's response to therapies such as continuous positive airway pressure (CPAP). 
PSG is distinguished from sleep studies by the inclusion of sleep staging. 
 
Criteria for coverage of Diagnostic Tests 
 
All reasonable and necessary diagnostic tests performed by sleep disorder clinics (Sleep Disorder Centers or 
Laboratories for Sleep Related Breathing Disorders) given for the medical conditions listed under Medical 
Conditions for Which Testing is Covered are covered, when all of the following criteria are met: 
 
The documentation should be retained in the patient's medical record. 
For a study to be reported as a polysomnogram, sleep must be recorded and staged. 
PSG is defined to include, but is not limited to, the following: 
 
A 1-4 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes 
placed on the scalp 
Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer canthus of each eye 
A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed 
over the mentalis, submentalis muscle, and/or masseter regions 
Rhythm electrocardiogram (ECG) with 2 or 3 chest leads 
Nasal and/or oral airflow 
Ventilation and respiratory effort by chest-wall and abdominal movement measured using strain gauges, 
piezoelectric belts, inductive plethysmography, impedance or inductance pneumography, endoesophageal 
pressure, or by intercostal EMG 
Gas exchange (oxygen saturation) by oximetry, transcutaneous monitoring, or end-tidal gas analysis 
Extremity muscle activity, motor activity-movement using EMG 
Body positions via mercury switches or by direct observation 
Recordings of vibration (frequency and/or volume) may be recorded 
Transcutaneous carbon dioxide (CO2), esophageal, penile tumescence, and bipolar EEG 
 
Sleep studies are performed in a hospital, sleep laboratory or by an Independent Diagnostic Treatment Facility 
(IDTF) that is supervised by a physician trained in analyzing and interpreting the recordings and should be 
attended by a trained technologist.  
 
You can find these rules in the Local Coverage Determination (LCD) Polysomnography L36593. 
 
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 43 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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that for a blepharoptosis repair: 
 
1. A margin reflex distance (MRD sometimes referred to as MRD1)) of 2.0 mm or less. The MRD is a 
measurement from the corneal light reflex to the upper eyelid margin (NOT any overhanging skin 
that may be present causing pseudoptosis) with the brows relaxed, and 
 
2. If applicable, the presence of Herring's effect (related to equal innervation to both upper eyelids) 
defending bilateral surgery when only the more ptotic eye clearly meets the MRD criteria (i.e., if lifting 
the more ptotic lid with tape or by instillation of phenylephrine drops into the superior fornix causes the 
less ptotic lid to drop downward and meet the strict criteria, the less ptotic lid is also a candidate for 
surgical correction. 
 
You can find this information in the Local Coverage Determination: Blepharoplasty, Eyelid Surgery, and Brow 
Lift (L36286). 
 
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 when services are furnished in a mobile unit, they are often provided to serve an entity for 
which another place of service (POS) code exists. For example, a mobile unit may be sent to a physicians 
office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already 
exists, providers should use the POS code for that entity. However, if the mobile unit is not serving an entity 
which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. 
Apply the nonfacility rate to payments for services designated as being furnished in POS code 15; apply the 
appropriate facility or nonfacility rate for the POS code designated when a code other than the mobile unit code 
is indicated. You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5. 
 
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 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 include 
coverage for dental service codes 21048 or 41899. You can find this information in Chapter 4 on page 37 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 the entitys NPI, when required, is entered in block 33a of the claim form. You can find this 
rule in the Center for Medicare Services (CMS) Internet-Only Manual Publication 100-04, Medicare Claims 
Processing Manual, Chapter 1, Section 30.2.13. 
 
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 state that one to two levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a three or four-level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. A session is a time period, which includes all 
procedures that are performed during the same day. You can find these rules in Local Coverage Determination 
(LCD) Facet Joint Interventions for Pain Management (L34892). 
 
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 $300 copayment per day for days 1 through 6 per benefit period. The 
Plan contract also says that the copayment applies on the date of admission but not on the date of discharge. 
You can find this information on pages 80 and 81 of the Plan's 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 local Medicare coverage of such 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: 
 
a. Analytical and clinical validation reports for Clinical Laboratory Improvement Amendments (CLIA), 
including the test description, intended use, and indications for testing. 
b. 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). 
c. 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). 
 
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.