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 state that TAVR is covered for the treatment of symptomatic aortic valve stenosis when furnished 
according to a Food and Drug Administration (FDA)-approved indication and when all of the following 
conditions are met: 
 
The procedure is furnished with a complete aortic valve and implantation system that has received FDA 
premarket approval (PMA) for that system's FDA approved indication. 
 
The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-
disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication 
across medical specialties to offer optimal patient-centered care. The heart team includes the following: 
Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who 
have: 
independently examined the patient face-to-face, evaluated the patients suitability for surgical aortic valve 
replacement (SAVR), TAVR or medical or palliative therapy; 
documented and made available to the other heart team members the rationale for their clinical judgment. 
Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and 
administrators. 
 
The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-
operative technical aspects of TAVR. 
 
TAVR must be furnished in a hospital with the appropriate infrastructure that includes but is not limited to: 
On-site heart valve surgery and interventional cardiology programs, 
Post-procedure intensive care facility with personnel experienced in managing patients who have undergone 
open-heart valve procedures, 
Appropriate volume requirements per the applicable qualifications below: 
There are two sets of qualifications; the first set outlined below is for hospital programs and heart teams 
without previous TAVR experience and the second set is for those with TAVR experience. 
 You can find this information in the National Coverage Determination (NCD) Transcatheter Aortic Valve 
Replacement (TAVR) 20.32. 
 
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 state that in most cases the manifestation codes will have in the code title, in diseases classified 
elsewhere. Codes with this title are a component of the etiology/ manifestation convention. The code title 
indicates that it is a manifestation code. In diseases classified elsewhere codes are never permitted to be used 
as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition 
code, and they must be listed following the underlying condition. You can find this information in the Centers 
for Medicare and Medicaid Services, You can find this information in the Centers for Medicare and Medicaid 
Services, ICD-10-CM Official Guidelines for Coding and Reporting FY 2022, Section 1.A.13. 
 
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: 
Indications for Myocardial Perfusion Imaging 
1. Acute myocardial infarction (AMI) - MPI is not typically performed during the acute period of myocardial 
infarction (MI), if the diagnosis is established by other means. In selected patients, imaging is appropriate in 
the assessment of: 
o Disease severity 
o Risk assessment and/or prognosis 
o Efficacy of acute reperfusion therapy 
o Evidence of myocardial salvage 
o Suspected infarction when the combination of history and other tests is not diagnostic 
2. Unstable angina - MPI may be useful as an adjunct to other tests in the diagnosis or treatment of unstable 
angina only when the combination of history and other tests is not diagnostic. In selected patients, imaging is 
appropriate for: 
o Identification of ischemia in the distribution of a known lesion or in remote areas 
o Identification of the severity/extent of disease in patients with medically unstable angina or 
ongoing ischemia 
o Measurement of left ventricular function (LVF) 
3. Chronic ischemic heart disease - The use of MPI is well established in the diagnosis and management of 
CAD and is covered in these situations: 
o Diagnosis of CAD, especially in patients with atypical chest pain 
o Evaluation of abnormal or suspected false positive stress ECG 
o Evaluation of other symptoms suspicious for the diagnosis of CAD such as syncope and 
ventricular arrhythmia o Assessment of myocardial viability after revascularization or medical management 
o Planning percutaneous transluminal coronary angioplasty (PTCA) to identify lesions causing 
ischemia, if unknown 
o Evaluation of suspected or known CAD prior to high risk surgical procedure 
o Identification of the presence, location, extent, and severity of myocardial ischemia 
o Assessment of drug therapy 
o Assessment of symptoms suggesting restenosis following PTCA 
o Assessment of symptoms suggesting ischemia following coronary artery bypass graft (CABG) 
o Follow up of symptomatic ischemic heart disease 
4. Congenital heart disease (CHD) - Echo is the method of choice for evaluating patients with known or 
suspected CHD. Selected patients may benefit from MPI when assessing for: 
o Diagnosis of anomalies of the coronary circulation 
o Kawasakis disease 
5. Post-transplant cardiac disease 
o Assessment of coronary arteriopathy 
o Evaluation for ventricular dysfunction with post-transplant rejection 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33457: Cardiac Radionuclide 
Imaging. 
 
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 $25 copayment for Physician/Practitioner services. You can find this 
information on page 105 of the Plan's 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 plans may offer a Point of Service (POS) option as a mandatory or optional supplemental 
benefit pursuant to 42 CFR 422.105 and 422.111. The POS benefit provides coverage for some plan-covered 
services outside of the plans network. The plan may either require or waive prior authorization rules for 
obtaining POS services. You can find this rule in You can find this information in the Centers for Medicare and 
Medicaid Services (CMS), 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 Plan 
contract states that prior authorization is required for out-of-network durable medical equipment (DME) and 
related supplies and for surgical supplies, such as dressings. You can find this information on pages 62 and 80 
of the Plan's 2023 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 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 34   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 CPT Manual defines modifier 25 as a significant, separately identifiable evaluation and management 
service by the same physician or other qualified health care professional on the same day of the procedure or 
other service. Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate 
that the E&M service is significant and separately identifiable from other services reported on the same date of 
service. The E&M service may be related to the same or different diagnosis as the other procedure(s). You can 
find this information in the CPT Coding Manual. 
 
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 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 pages 31-33 of the Plan's 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 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 lab services at urgent care center and outpatient 
hospital. You can find this information on pages 61 to 65 of the Plan's 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 say that CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and 
  
  Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations 
Manual, Section 220.1(A). 
 
The rules say that the single photon emission computed tomograph (SPECT) acquires information on the 
concentration of radionuclides introduced into the patient's body. It is useful in the diagnosis of several clinical 
conditions including: 
 
a. stress fracture. 
b. spondylosis. 
c. infection (e.g., discitis). 
d. tumor (e.g., osteoid osteoma). 
e. analyze blood flow to an organ, as in the case of myocardial viability. 
f. differentiate ischemic heart disease from dilated cardiomyopathy. 
 
You can find this rule in the National Coverage Determination (NCD) - Single Photon Emission Computed 
Tomography (SPECT) (220.12). 
 
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 $490 copayment per day, for days 1 to 4 and a $0 copayment for 
additional days of each inpatient stay. You can find this information on page 94 of the Plan's 2022 Evidence of 
Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $370 copayment for outpatient surgery/for other outpatient procedures 
and services. You can find this information on page(s) 96 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 state that nondiagnostic outpatient services that are related to a beneficiary's hospital admission and 
that are provided by the admitting hospital, or by an entity that is wholly owned or wholly operated by the 
admitting hospital (or by another entity under arrangements with the admitting hospital), to the patient during 
the 3 days immediately preceding and including the date of the beneficiary's admission are deemed to be 
inpatient services and are included in the inpatient payment. Effective March 13, 1998, we defined 
nondiagnostic preadmission services as being related to the admission only when there is an exact match (for 
all digits) between the principal diagnosis code assigned for both the preadmission services and the inpatient 
stay. Thus, whenever Part A covers an admission, the hospital may bill nondiagnostic preadmission services to 
Part B as outpatient services only if they are not related to the admission. The A/B MAC (A) shall assume, in 
the absence of evidence to the contrary, that such bills are not admission related and, therefore, are not deemed 
to be inpatient (Part A) services. 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, 40(C). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 codes E2310 and E2311 describe electronic components that allow the patient to control two 
or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or 
nonproportional interface: 
 
-Power tilt 
-Power recline, with or without shear reduction 
-Combination power tilt and recline, with or without shear reduction 
-Power leg elevation with or without articulation, power center mount elevating foot platform with or without 
articulating properties. 
 
You can find this rule in the Local Coverage Article (LCA) - Power Mobility Devices - Policy Article 
(A52498) - Effective January 1, 2020. 
 
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 $95 copayment for in-network outpatient diagnostic tests provided by an 
outpatient hospital. You can find this information on page(s) 63-68 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 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 $250 copayment for surgical services, 20% coinsurance on lab services. 
You can find this information on page 72 of the Plan's 2022 Evidence of Coverage (EOC).