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 a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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 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 pages 21-22 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 if a laboratory procedure produces multiple reportable test results, only a single procedure 
code shall be reported for the procedure. If there is no procedure code that describes the procedure, the 
laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. You can find 
this rule in National Comprehensive Coding Initiative (NCCI) Coding Policy Manual Chapter X, Section A. 
 
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 $45 copayment for diagnostic procedures and tests. You can find this 
information on page 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 that payment for inpatient psychiatric hospital services is to be made only for active treatment. 
For services to be designated as active treatment they must: 
  
  1. be provided under an individualized treatment or diagnostic plan; 
 
2. reasonably be expected to improve the patients condition, or for the purpose of diagnosis; and 
 
3. be supervised and evaluated by a physician.   
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 2, Sections 30.2.2 and 30.2.2.1. 
 
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary 
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services 
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section 
1862(a)(1). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say 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% coinsurance for an out-of-network specialist's office visit. You can 
find this information on pages 82 to 83 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 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 the claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected. Some claims that 
appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances 
of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers 
of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may 
appear to be duplicates, but, in fact, are not. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, 
Section 120.1. 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that testing methods that include (real-time) duplex scans and Doppler ultrasound waveform with 
spectral analysis are covered for the following: 
 
Indications: 
 
    Cervical bruits. 
    Amaurosis fugax (transient monocular blindness). 
    Focal cerebral or ocular transient ischemic attacks. 
    Drop attack or syncope is only covered with vertebrobasilar or bilateral carotid artery disease as suggested 
by the patients history. If an echocardiogram is negative for a cardiac or cardiac valvular cause, it may be 
medically appropriate to perform extracranial arteries studies for the drop attack or syncope. 
    Subclavian steal syndrome (symptoms usually associated with it are a bruit in the subclavian fossa, unequal 
radial pulses, arm claudication following minimal exercise, and a difference of 20 mm Hg or more between the 
systolic blood pressures in the arms). 
    Evaluation of blunt or penetrating neck trauma or injury to the carotid artery. 
    Follow-up after a carotid endarterectomy or carotid stenting. 
    Suspected aneurysm of the carotid artery. Patients with swelling of the neck particularly if occurring post 
carotid endarterectomy. 
    Re-evaluation of existing carotid stenosis. 
    Evaluation of pulsatile neck mass. 
    Preoperative evaluation of patient scheduled for major cardiovascular surgical procedure when there is 
evidence of systemic atherosclerosis. 
    Preoperatively validate the degree of carotid stenosis of patients whose previous duplex scan revealed a 
greater than 60% diameter reduction. The duplex is only covered when the surgeon questions the validity of the 
previous study and the repeat test is performed in lieu of a carotid arteriogram. 
    Ocular micro embolism (optic nerve/retinal arterial - Hollenhorst plaques/ocular). 
    Evaluation of suspected dissection. 
    Recent stroke (defined as less than six months) for determining the cause of the stroke. 
    Vasculitis involving the extracranial carotid arteries. 
    Diagnosis of carotid disease on medical management and cerebrovascular symptoms are reoccurring. 
    Pulsatile tinnitus with other symptoms involving the cardiovascular system. 
 
 Limitations: 
Tests may not be considered medically necessary if performed for the following signs and symptoms: 
 
    Dizziness is not a typical indication unless associated with other localizing neurologic signs or symptoms. 
    Headaches including migraines. 
    Temporarily blurred vision. 
 
You can find this information in the Local Coverage Determination (LCD) Non-Invasive Cerebrovascular 
Studies (L35753). 
 
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 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 26 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 state that indications for immunotherapy are determined by appropriate diagnostic procedures 
coordinated with clinical judgment and knowledge of the natural history of allergic diseases. The following 
indications are considered medically reasonable and necessary for allergy immunotherapy: 
 
1. Controlled studies have shown that allergen immunotherapy is effective for patients with: 
 
a. Allergic rhinitis, 
b. Allergic conjunctivitis, 
c. Allergic asthma, and 
d. Stinging insect hypersensitivity. 
 
Allergen-induced asthma is an indication for immunotherapy along the guidelines for allergic rhinitis when 
there is a poor response to environmental control or pharmacologic treatment. Allergen immunotherapy in 
asthmatic patients should not be initiated unless the patients asthma is stable. Patients with severe or 
uncontrolled asthma are at increased risk for systemic reactions to immunotherapy injections. You can find this 
information in the Local Coverage Determination (LCD) Allergy Immunotherapy L36408. 
 
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 for dates of service on and after July 2, 2019, the Centers for Medicare & Medicaid 
Services (CMS) believes that the evidence is sufficient to determine that ABPM is reasonable and necessary for 
the diagnosis of hypertension in Medicare beneficiaries under the following circumstances: For beneficiaries 
with suspected white coat hypertension, which is defined as average office BP of systolic BP > 130 mm Hg but 
< 160 mm Hg, or diastolic BP > 80 mm Hg but < 100 mm Hg on two separate clinic/office visits with at least 
two separate measurements made at each visit, and with at least two BP measurements taken outside the office 
which are < 130/80 mm Hg. 1. For beneficiaries with suspected masked hypertension, which is defined as 
average office BP between 120 mm Hg and 129 mm Hg for systolic BP, or between 75 mm HG and 79 mm Hg 
for diastolic BP on two separate clinic/office visits with at least two separate measurements made at each visit, 
and at least two BP measurements taken outside the office which are = 130/80 mm Hg. 2. ABPM devices must 
be: capable of producing standardized plots of BP measurements for 24 hours with daytime and night-time 
windows and normal BP bands demarcated; and,  provided to patients with oral and written instructions and a 
test run in the physicians office must be performed; and,   interpreted by the treating physician or treating 
non-physician practitioner. For eligible patients, ABPM is covered once per year.You can find this information 
in the National Coverage Determination NCD - Ambulatory Blood Pressure Monitoring (20.19) 
 
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 an electrocardiogram (ECG) is indicated to diagnose or treat a patient for symptoms, signs, 
or a history of heart disease, or systemic conditions that affect the heart, including: 
 
-Chest pain or angina pectoris, 
-Myocardial ischemia or infarction, 
-Arteriovascular disease including coronary, central, and peripheral disease, 
-Hypertension, 
-Conduction abnormalities, 
-Cardiac rhythm disturbances, 
-Cardiac hypertrophy, 
-Heart failure, 
-Pericarditis, 
-Structural cardiac conditions, 
-Endocrine abnormalities, 
-Neurological disorders affecting the heart, 
-Syncope, 
-Paroxysmal weakness, 
-Palpitations, 
-Sudden lightheadedness, 
-Electrolyte imbalance, 
-Acid-base disorders, 
-Temperature disorders, 
-Pulmonary disorders, and 
-Drug cardiotoxicity. 
 
You can find this rule in the Local Coverage Determination (LCD) - Electrocardiograms (L34315) - Effective 
October 1, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
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 for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit 
category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory 
requirements. Wheelchair options and accessories are covered under the Durable Medical Equipment benefit 
(Social Security Act 1861(s)(6)). You can find this rule in the Local Coverage Article for Wheelchair 
Options/Accessories, 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.
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 JAK2 V617F genotyping is considered medically necessary in the initial diagnostic work-up 
of BCR-ABL negative, JAK2-negative adults with clinical, laboratory, or pathological findings suggesting 
myeloproliferative neoplasm (MPN) (polycythemia vera (PV), essential thrombocythemia (ET) or primary 
myelofibrosis (PMF)) or a myelodysplastic syndrome (MDS). Note: JAK2 (exons 12 and 13) (reported with 
81403) is medically necessary in individuals for whom PV is a strong consideration. You can find this rule at 
Local Coverage Article (LCA) A56199: Billing and Coding: Molecular Pathology Procedures (eff. 5/1/22). 
 
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 that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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 the claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected. Some claims that 
appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances 
of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers 
of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may 
appear to be duplicates, but, in fact, are not. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, 
Section 120.1. 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 66-67 of the Plan's 2022 Evidence of Coverage.