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 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, for ambulance service claims, institutional-based providers and suppliers must report an 
origin and destination modifier for each ambulance trip provided in HCPCS/Rates. Origin and destination 
modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, 
with the exception of X, represents an origin code or a destination code. The pair of alpha codes creates one 
modifier. The first position alpha code equals origin; the second 
position alpha code equals destination. The origin code for skilled nursing facilities is N. The destination code 
for hospitals is H. You can find this information in the Centers for Medicare and Medicaid Service, Internet-
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 15: Ambulance, Section 30.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 state that Medicare will make payment for the services related to the surgery when furnished by the 
physician who performs the surgery, as part of a global surgical package. The services included in the global 
surgical package may be furnished in any setting. The rules go on to say that a modifier of -79 reports an 
unrelated procedure by the same physician during a postoperative period. The physician may need to indicate 
that the performance of a procedure or service during a postoperative period was unrelated to the original 
procedure. You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 40: Surgeons and Global Surgery, 
Section 40.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 Percutaneous Transluminal Angioplasty (PTA) is covered when used under the following 
conditions: 
1. Treatment of atherosclerotic obstructive lesions 
2. Concurrent with carotid stent placement in Food and Drug Administration (FDA)-Approved Category B 
Investigational Device Exemption (IDE) clinical trials 
3. Concurrent with carotid stent placement in FDA-Approved post-approval studies 
4. Concurrent with carotid stent placement in patients at high risk for Carotid Endarterectomy (CEA) 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 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 state that therapeutic facet joint procedures are considered medically reasonable and necessary for 
patients who meet ALL of the following criteria: The patient has had two (2) medically reasonable and 
necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of 
primary (index) pain (with the duration of relief being consistent with the agent used); and subsequent 
therapeutic facet joint procedures at the same anatomic site result in at least consistent 50% pain relief for at 
least three (3) months from the prior therapeutic procedure or at least 50% consistent improvement in the 
ability to perform previously painful movements and ADLs as compared to baseline measurement using the 
same scale; and documentation of why the patient is not a candidate for radiofrequency ablation (such as 
established spinal pseudarthrosis, implanted electrical device) is in the medical record. You can find this rule in 
the Medicare Local Coverage Determination (LCD)- L34892, Facet Joint Interventions for Pain Management. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say to interpret the phrase "new patient" to mean a patient who has not received any professional 
services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or 
physician group practice (same physician specialty) within the previous 3 years. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 12, Section 30.6.7(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 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 home health payments must be based upon the site at which the beneficiary is served. For 
certain dates of service when required by law, payments may be further adjusted if the site is in a rural core 
based statistical area (CBSA) or rural county. For periods of care in which the beneficiary's site of service 
changes from one CBSA or county to another within the period, home health agencies (HHAs) should submit 
the CBSA code or State and County code corresponding to the site of service at the end of the period. For code 
61, HHAs report the Core Based Statistical Area (CBSA) number (or rural state code) of the location where the 
home health or hospice service is delivered. The HHA reports the number in dollar portion of the form locator 
right justified to the left of the dollar/cents delimiter, add two zeros to the cents field if no cents. For code 85, 
where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and 
County Code of the place of residence where the home health service is delivered. If more than one value code 
is shown for a billing period, codes are shown in ascending numeric sequence. There are four lines of data, line 
"a" through line "d." The provider uses FLs 39A through 41A before 39B through 41B. You can find this rule 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, Chapter 10, Section 40.2, and 
Chapter 25, Section 75.3. 
 
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.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) is 
only covered when the individual has unique characteristics which prevent them from receiving adequate 
satisfactory pneumatic compression treatment using a nonsegmented device along with a segmented appliance 
or compression device without manual control of the pressure in each chamber. You can find this information 
in the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). 
 
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).    
 
The rules say subluxation may be shown by x-ray or physical exam. You can find thus rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 15, Section 240.1.2. 
 
The rules say that Medicare does not cover chiropractic maintenance care. When further clinical improvement 
cannot be reasonably expected from ongoing care, the care is considered maintenance. 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 240.1.3(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. 
 
Total knee arthroplasty (TKA) is considered reasonable and necessary for individuals with one or more of the 
following*:  
  
  1. Advanced Joint disease and all of the following (a,b,c):  
a. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging 
(MRI)*; and 
b. Pain or functional disability attributable to the advanced joint disease; and 
c. Unsuccessful non-surgical medical management*, when appropriate, and attempted for a 
minimum of 3 months. (When non-surgical medical management is not appropriate, the medical 
record must clearly document the basis for that conclusion); 
or 
2. Failure of a previous osteotomy; or 
3. Distal femur fracture; or 
4. Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or 
5. Failure of previous unicompartmental knee replacement; or 
6. Avascular necrosis of the knee; or 
7. Proximal tibia fracture 
 You can find this rule in the Local Coverage Determination (LCD): Total Joint Arthroplasty (L36039). 
 
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 a PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in 
beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 
 
    1. The beneficiary has a diagnosis of lymphedema as defined above, and 
    2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented 
presence of at least one of the following clinical findings: 
            a. Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
            b. Papillomatosis cutis lymphostatica, 
            c. Deformity of elephantiasis, 
            d. Skin breakdown with persisting lymphorrhea, 
            e. Detailed measurements over time confirming the persistence of the lymphedema with a history 
evidencing a likely etiology, and 
    3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to 
other clinical treatment over the course of a required four-week trial. 
 
A four-week trial of conservative therapy demonstrating failed response to treatment is required. The four-
week trial of conservative therapy must include all of the following: 
 
    1. Regular and compliant use of an appropriate compression bandage system or compression garment to 
provide adequate graduated compression 
            a. Adequate compression is defined as (1) sufficient pressure at the lowest pressure point to cause fluid 
movement, and (2) sufficient pressure across the gradient (from highest to lowest pressure point) to move fluid 
from distal to proximal. The compression used must not create a tourniquet effect at any point. 
            b. The garment may be prefabricated or custom-fabricated but must provide adequate graduated 
compression starting with a minimum of 30 mmHg distally. 
    2. Regular exercise 
    3. Elevation of the limb 
 
When available, manual lymphatic drainage is a key component of conservative treatment as is appropriate 
medication treatment when there is concurrent congestive failure. 
 
You can find this information in the Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, 
CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, 
such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. This 
benefit covers up to 12 sessions in a 90-day period, and up to 20 visits per year, if there is demonstrated 
improvement. Treatment must be discontinued if there is no improvement or regression. These treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. You can find this information in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage 
Determinations Manual, Section 30.3.3. 
 
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 also says that acupuncture services are only covered for chronic low back pain. You can find this 
information on page 63 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 that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. 
 
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. 
 
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. 
 
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the 
patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-
injection. The only exceptions are: 
 
1. blood-clotting factors;  
2. drugs used in immunosuppressive therapy; 
3. erythropoietin for dialysis patients;  
4. osteoporosis drugs for certain homebound patients; 
5. certain oral cancer drugs;  
6. oral anti-emetics used in certain situations;  
7. drugs treated as supplies during an outpatient hospital procedure; and  
8. drugs required for the effective use of durable medical equipment. 
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, Sections 50, 50.2, 50.5, and 110.3. 
 
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 enrollees must pay a $40 copay for outpatient rehabilitation services in an outpatient hospital. 
You can find this information on pages 79-80 of the Plan's 2021 Evidence of Coverage.  
 
The Plan contract says that enrollees must pay a $345 copay for outpatient surgery services in an outpatient 
hospital. You can find this information on page 81 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 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. 
 
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 NEMT could be covered only if you submit a complete Physician Certification 
Statement (PCS) form by the treating physician. You can find this information on page 101 of the Plan's 2022 
Evidence of Coverage.