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 modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
The rules say that for procedure codes 64400-64530 (Peripheral nerve blocks - bolus injection or continuous 
infusion) may be reported on the date of surgery if performed for postoperative pain management only if the 
operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of the 
intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve block codes shall not 
be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic 
technique or as a supplement to the primary anesthetic technique. Modifier 59 or XU may be used to indicate 
that a peripheral nerve block injection was performed for postoperative pain management, rather than 
intraoperative anesthesia, and a procedure note shall be included in the medical record. You can find this rule 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative 
Policy Manual, Chapter 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 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). 
 
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 there is a $300 deductible which applies to certain items and services. The Plan 
deductible applies to an office visit. You can find this information on page 36 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 there should be a direct correlation between those positive findings generated from 
presumptive testing and those requested definitive tests to specifically confirm such findings. Definitive urine 
drug testing (UDT) may be reasonable and necessary based on patient specific indications, including historical 
use, medication response, and clinical assessment, when accurate results are necessary to make clinical 
decisions. The clinicians rationale for the definitive UDT and the tests ordered must be documented in the 
patients medical record. You can find this rule in the Local Coverage Determination (LCD) - Controlled 
Substance Monitoring and Drugs of Abuse Testing (L35006) - Effective October 17, 2019. 
 
The rules say that definitive urine drug testing (UDT) is reasonable and necessary in order to: 
 
1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
2. Definitively identify specific drugs in a large family of drugs; 
3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
6. Rule out an error as the cause of a presumptive UDT result; 
7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
You can find this rule in the Local Coverage Determination (LCD) - Controlled Substance Monitoring and 
Drugs of Abuse Testing (L35006) - Effective October 17, 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. 
 
The rules state that the following are covered indications for nerve blockades: 
 
PERIPHERAL NEUROPATHY 
 
 Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral 
neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve 
blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain. 
 The use of imaging guidance (i.e. ultrasound, CT, or fluoroscopic guidance) in conjunction with these non-
covered injections is also considered not medically necessary. 
 The use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies 
caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are 
considered investigational. Medical management using systemic medications is clinically indicated for the 
treatment of these conditions. 
 
SOMATIC NERVE BLOCK 
 
 Radiculopathy and other neurological deficits require further evaluation and management prior to performing 
the blocks. 
 
EPIDURAL BLOCK (Cervical and Thoracic) 
 
This policy does not cover lumbar epidural blocks, which are covered in another Noridian policy. 
 
 Injections should not be repeated in less than five days. 
 Injections are limited to a total of three in a three to six month period of time and should only be repeated if 
the injections produced significant and sustained relief documented by objective evidence, including 
improvements in the ability to perform activities of daily living (ADLs). 
 Steroids should be used only in the presence of radiculopathy. Particulate steroids in the cervical region have 
been shown to be hazardous. 
 
You can find this rule in the Local Coverage Determination (LCD) for Nerve Blockade for Treatment of 
Chronic Pain and Neuropathy (L35457). 
 
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 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 contract 
says that you must pay a $45 copayment for specialist's office visits for Medicare Covered vision services. 
Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contacts. The Plan 
contract says that you can receive vision benefits through a Plan approved vision care provider. The contract 
also says that any benefits received at a non-network optical provider are excluded from coverage. You can 
find this information on pages 83, 84, 88, and 92 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 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 in-network Part B drugs. You can find this 
information on page 4-42 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $35 copayment for an in-network specialist office visit. You 
can find this information on page 4-60 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 state that durable medical equipment providers are required to keep proof of delivery records.  The 
Proof of Delivery documents must include the following elements: the beneficiary's name, the delivery address, 
the delivery service's package identification number, a description of the items being delivered (such as a 
narrative description, a code, or a brand/item number), the quantity delivered, the date delivered, and evidence 
of delivery.  You can find this rule at Medicare Local Coverage Article A55426 entitled Standard 
Documentation Requirements for all Claims Submitted to DME MACs. 
 
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 $30 copayment per visit to a specialist. You can find this information on 
page 83-84 of the Plan's 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 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 $200 copay per one-way trip. You can find this information in Chapter 4 
on page 67 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 will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(C). 
The rules say that Medicare Advantage (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. 
 
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 durable medical equipment suppliers must be Medicare-certified in order to receive 
payment for a Medicare-covered item. You can find this rule at 42 CFR 424.57. 
 
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 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, the Plan cannot pay a provider who as opted 
out of or been excluded or precluded from the Medicare program.  If you go to a provider who 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 on page 3-4 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 leadless pacemakers are non-covered when furnished outside of a CMS approved CED 
study. You can find this information in the National Coverage Determination (NCD): Leadless Pacemakers 
(20.8.4). 
 
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.
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 $50 copayment for Medicare-covered urgently needed care when 
services are provided at an in- and out-of-network urgent care center. You can find this information on page 
102 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 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 $15 copayment for each Tier 2 PCP (standard benefit) Medicare-covered 
primary care doctor visit. You can find this information on page 93 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 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). 
 
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 there is a $195 deductible which applies to certain items and services. The Plan 
deductible applies to the lab services. You can find this information on pages 62-65 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 state that an expandable controller is capable operating 3 or more powered seating actuators through 
the drive control. (Note: Control of the power seating actuators though the Control Input Device would require 
the use of an additional component, E2310 or E2311.) 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. 
 
Power seat elevation features (E2300) are non-covered because they are not primarily medical in nature. If a 
wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of 
the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. 
 
You can find these rules Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). 
 
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.