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 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 $35 copayment for each specialist office visit. You can find this 
information on pages 84-85 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 $0 copayment for days 1-20 of a skilled nursing facility stay. The 
contract also says the enrollee must pay a $184 copayment per day for days 21-100 per benefit period. The Plan 
contract says that a benefit period begins on the first day you go to a skilled nursing facility and the benefits 
period ends when you have not been an inpatient at any skilled nursing facility for 60 days in a row. You can 
find this information on pages 105-106 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 enrollees must pay a $0 copayment for other diagnostic procedures and tests at a physicians 
office and a $125 copayment for other diagnostic procedures and tests at any other location. You can find this 
information page 71 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 state that other eyelid surgeries may be considered reconstructive in nature for the following 
indications where there is functional impairment as documented by preoperative frontal and lateral 
photographs: 
 
    Ectropion, entropion, or epiblepharon repair for corneal and/or conjunctival injury 
    Disease due to ectropion, entropion, trichiasis, or epiblepharon 
    Poor eyelid tone (with or without entropion) that causes lid retraction and exposure keratoconjunctivitis and 
often, epiphora 
    Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent 
visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic 
syndrome) and is unresponsive to documented conservative medical management. 
 
You can find this information in the Local Coverage Determination (LCD) Blepharoplasty, Eyelid Surgery, and 
Brow Lift (L34411). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 $75.00 copay for each covered diagnostic procedure or test at a network 
doctor's office. You can find this information on page 80 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 state percutaneous transluminal angioplasty (PTA) services will only be covered for enrollees who 
are symptomatic with carotid artery stenosis of greater than 70%. You can find this rule in Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, National Coverage Determination 
(NCD): Percutaneous Transluminal Angioplasty (PTA) (20.7). 
 
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 bariatric surgery is covered for enrollees who have:  
 
(1) a body mass index (BMI) of greater than or equal to 35;  
 
(2) at least one co-morbidity related to obesity; and 
 
(3) been unsuccessful with medical treatment for obesity.   
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 100.1. 
 
The rules also say that repeat bariatric surgery is generally not reasonable and necessary. Medicare does not 
provide prior authorization for these services. Claims for more than one bariatric surgical procedure most likely 
will create a denial. However, in the appeals process, medical documentation may be submitted for review and 
the service may potentially be covered when clinical circumstances demonstrate reasonability and necessity. 
Appropriate ABN and modifiers should be appended to any services potentially to be denied. Refer to IOM 
Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 15 for more information. 
 
You can find this information in the Local Coverage Determination (LCD) Bariatric Surgical Management of 
Morbid Obesity (L35022). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 intravenous immune globulin (IVIG) is covered if all of the following criteria are met: 
 
    It is an approved pooled plasma derivative for the treatment of primary immune deficiency disease; and 
    The patient has a diagnosis of primary immune deficiency disease (See Diagnosis Codes that Support 
Medical Necessity section below); and 
    The IVIG is administered in the home; and 
    The treating practitioner has determined that administration of the IVIG in the patients home is medically 
appropriate. 
 
If all of the criteria are not met and the IVIG is not administered with an infusion pump, the IVIG will be 
denied as noncovered - no benefit category. 
 
You can find this information in the Local Coverage Article (LCA) Intravenous Immune Globulin (A52509). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 70 and 71 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 ambulance services are only covered when the patient's clinical condition is such that other 
methods of transport are contraindicated. You can find this rule at 42 CFR Section 410.40(e). 
 
The rules say that, during the public health emergency (PHE) for the COVID-19 pandemic, a covered 
ambulance destination includes a ground ambulance transport from any point of origin to a destination that is 
equipped to treat the condition of the patient consistent with state and local Emergency Medical Services 
(EMS) protocols where the services will be furnished. This expanded list of destinations will apply to 
medically necessary emergency and non-emergency ground ambulance transports of beneficiaries during the 
PHE for the COVID-19 pandemic. You can find this rule in 42 Code of Federal Regulations (CFR), Section 
410.40(f)(5) as amended by Interim Final Rule CMS-1744-IFC, Section II(AA). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
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 40% coinsurance for surgery services performed by an out-of-network 
provider. You can find this information on pages 77-79 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 state that for wounds and ulcers described under A or B above, a NPWT pump and supplies will be 
denied as not reasonable and necessary with any of the following, whichever occurs earliest: 
 
            Criteria C1-C2 cease to occur, 
 
            In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that 
NPWT may be discontinued, 
 
            Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is 
defined as improvement occurring in either surface area (length times width) or depth of the wound 
 
            4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) 
have elapsed using a NPWT pump in the treatment of the most recent wound 
 
            Once equipment or supplies are no longer being used for the beneficiary, whether or not by the treating 
practitioners order 
 
You can find this information in the Local Coverage Determination (LCD): Negative Pressure Wound Therapy 
Pumps (L33821). 
 
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. 
 
Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion 
does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the 
cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. You can find 
this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 290(3). 
 
The rules say inserts and other shoe modifications (L3000, L3001, L3002, L3003, L3010, L3020, L3030, 
L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, 
L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, 
L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and 
L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically 
necessary for the proper functioning of the brace. You can find this rule in the Centers for Medicare and 
Medicaid Services, Local Coverage Article: Orthopedic Footwear - Policy Article (A52481). 
 
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 facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity. 
 
You can find this rule in the Local Coverage Determination for Facet Joint Interventions for Pain Management, 
L35936 (eff 02/10/22).  
 
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 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. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 4, Section 40.1. 
 
The 'integrated' Outpatient Code Editor (I/OCE) program processes claims for all outpatient institutional 
providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as 
hospitals that are NOT (Non-OPPS). Claim will be identified as 'OPPS' or 'Non-OPPS' by passing a flag to the 
OCE in the claim record, 1=OPPS, 2=non-OPPS; a blank, zero, or any other value is defaulted to 1. This 
version of the OCE processes claims consisting of multiple days of service. The OCE will perform three major 
functions: 
 
1. Edit the data to identify errors and return a series of edit flags.  
2. Assign an Ambulatory Payment Classification (APC) number for each service covered under OPPS and 
return information to be used as input to a PRICER program.  
3. Assign an Ambulatory Surgical Center (ASC) payment group for services on claims from certain non-OPPS 
hospitals. 
 
Edit 72: Service not billable to the Medicare Administrative Contractor. A code has a status indicator M. This 
edit is bypassed when the bill type is 85x and revenue code is 096x, 097x, or 098x. This edit is also bypassed 
when the bill type is 81X or 82X and the revenue code is 657. 
 
You can find this rule at CMS.gov Integrated OCE (IOCE) CMS Specifications V22.2 effective July 1, 2021. 
 
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 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). 
 
The rules say that to be covered for a left atrial appendage closure the patient must have a CHADS2 score  2 
and suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the 
conclusion of shared decision making, as left atrial appendage closure is only covered as a second line therapy 
to oral anticoagulants. You can find this information in the National Coverage Determination (NCD) 20.34: 
Percutaneous Left Atrial Appendage Closure. 
 
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 the following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): Gradient 
compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, 
A6544, A6549). You can find this information in Medicare's 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.