Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare 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 page 94 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that 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 following tests may be billed in the post-biopsy setting (after a negative or non-malignant
biopsy, as defined in the policy) for individuals contemplating a repeat biopsy:

 Progensa PCA3 assay (CPT 81313), performed on post-digital rectal exam (DRE) urine specimens.
 ConfirmMDx assay (CPT 81551), performed on formalin-fixed, paraffin embedded (FFPE) tissue
specimens.

You can find this in the Medicare Local Coverage Article (LCA) Billing and Coding: MolDX: Molecular
Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (A58718).

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 Direct to definitive UDT without a presumptive UDT is reasonable and necessary, when 
individualized for a particular patient, in the following circumstances: 
a. To identify a specific substance or its metabolite that is in a large class of drugs, or that is inadequately 
detected or not detected by presumptive UDT, such as fentanyl, meperidine, synthetic cannabinoids, 
and other synthetic/analog drugs. 
b. For use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
c. To identify non-prescribed medication or illicit substance use for ongoing safe prescribing of controlled 
substances, where clinician has documented concerns related to safety risks attendant to failure to 
identify specific substances suspected based upon clinical review and judgment; or 
d. To identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of delta-9-tetrahydrocannabinol (THC) use according to a treatment plan). 
You can find the rules in Local Coverage Determination (LCD) Controlled Substance Monitoring and Drugs of 
Abuse Testing L36393. 

 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 a standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of 
the following criteria (1-3) are met: 
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
 
A mobility limitation is one that: 
a. Prevents the beneficiary from accomplishing the MRADL entirely, or 
b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform the MRADL, or 
c. Prevents the beneficiary from completing the MRADL within a reasonable time frame; and 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
If all of the criteria are not met, the walker will be denied as not reasonable and necessary. You can find this 
rule in Local Coverage Determination (LCD) Walkers L33791. 

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 definitive UDT is reasonable and necessary for the following circumstances:

-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT 
screen;
-Definitively identify specific drugs in a large family of drugs;
-Identify a specific substance or metabolite that is not detected by presumptive UDT;
-Identify drugs when a definitive concentration of a drug is needed to guide management;
-Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a 
patient's self- report, presentation, medical history, or current prescribed pain medication plan;
-Rule out an error as the cause of an unexpected presumptive UDT result;
-Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled 
substances; and
-Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions.

Definitive 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 clinician's rationale for the definitive UDT and the tests ordered must be documented in the patient's medical record.

You can find this information in Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L36393).

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 must report services correctly. Procedures should be reported with the Current 
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the 
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that effective for claims with dates of service July 1, 2007, and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The I/OCE 
instructions and specifications are provided via Recurring Update Notifications. They are also posted on the 
Web at the following address 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.  
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
The rules say that I/OCE edit 18 is invoked when a line submitted on an outpatient claim has a status indicator 
of C and is not on the separate procedure list, or a line has a C status indicator and is on the separate 
procedure list, but there are no type T lines on the same day, all other line items on the same day as the line with the C status indicator are denied and edit 49 is assigned on all line items. This is the only edit that can 
cause one or more days of a multiple day claim to be denied, or single day claim with all lines denied. No other 
edits are performed on any lines with edits 18 or 49. The disposition for each of these edits is Line Item Denial 
(LID) which means that there are one or more edits present that cause one or more individual line items to be 
denied. A line item denial means that the claim can be processed for payment with some line items denied for 
payment. The line item cannot be resubmitted but can be appealed. 
 
You can find this information in the Integrated OCE Centers for Medicare and Medicaid Services (CMS) 
Specifications V24.1 Effective April 1, 2023. 
 
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 outpatient non-diagnostic services, other than ambulance and maintenance renal dialysis 
services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, 
second, and third calendar days for a subsection (d) hospital paid under the inpatient prospective payment 
system (IPPS) preceding the date of a beneficiary's inpatient admission are deemed related to the admission, 
and thus, must be billed with the inpatient stay, unless the hospital attests to specific non-diagnostic services as 
being unrelated to the hospital claim (that is, the preadmission non-diagnostic services are clinically distinct or 
independent from the reason for the beneficiary's admission) by adding a condition code 51 (definition "51 - 
Attestation of Unrelated Outpatient Non-diagnostic Services") to the separately billed outpatient non-diagnostic 
services claim. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2.6.D. 
 
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 the global surgery package of procedures with a global period of 10 or 90 days includes all 
additional medical or surgical services required of the surgeon during the postoperative period of the surgery 
because of complications which do not require additional trips to the operating room, follow-up visits during 
the postoperative period of the surgery that are related to recovery from the surgery, among other related 
services. In order to report an unrelated evaluation and management (EM) service by same physician during a 
postoperative period, modifier -24 must be used. Services submitted with the -24 modifier must be sufficiently 
documented to establish that the visit was unrelated to the surgery. 
 
Evaluation and management services on the day before major surgery or on the day of major surgery that result 
in the initial decision to perform the surgery are not included in the global surgery payment for the major 
surgery and, therefore, may be billed and paid separately. In addition to the CPT evaluation and management 
code, modifier "-57". 
 
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, Sections 40.1 and 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 for any DMEPOS item to be covered by Medicare, the patient's medical record must contain 
sufficient documentation of the patient's medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement (if applicable). The information should 
include the patient's diagnosis and other pertinent information including, but not limited to, duration of the 
patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare 
Program Integrity Manual, Chapter 5, Section 5.7.  
 
The rules say that a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1852), is covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). Knee orthoses L1852 are also covered for a beneficiary who is ambulatory and has 
knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-related Policy Article. 
For code L1852, knee instability must be documented by examination of the beneficiary and objective 
description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims for L1832, 
L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the 
beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a 
subjective description of joint instability is documented. Addition codes will be denied as not reasonable and 
necessary if the base orthosis is not reasonable and necessary or the addition is not reasonable and necessary. 
You can find this rule in the Local Coverage Determination for Knee Orthoses. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 36 one-way trips each year. You can find this information on page 95 of the Plans 2023 Evidence 
of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that effective May 12, 2023, COVID-19 over the counter (OTC) tests are no longer a covered 
benefit for Medicare. You can find this information in Bulletins - Medicare Part A and B - Noridian 
Administrative Services. 
 
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 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 in Chapter 3 on pages 37 to 38 of 
the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 CMS requires that surgical pathology, including gross and microscopic examination, of any 
and all submitted prostate needle biopsy specimens from a single patient be reported with one unit of service of 
HCPCS code G0416 rather than CPT code 88305. You can find this rule in the Centers for Medicare and 
Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 
X, Section L(10). 
 
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.