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 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 routine transportation for up to 72 one-way trips each year. Each one-way trip must not 
exceed 50 miles of driving distance. You can find this information on page 119 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 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 testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically 
appropriate but is considered screening and therefore, not covered by Medicare. The US Preventive Services 
Task Force has concluded that screening for asymptomatic bacteriuria outside of the narrow indication for 
pregnant women is generally not indicated. There are insufficient data to recommend screening in ambulatory 
elderly patients including those with diabetes. Testing may be clinically indicated on other grounds including 
likelihood of recurrence or potential adverse effects of antibiotics but is considered screening in the absence of 
clinical or laboratory evidence of infection. You can find this rule in National Coverage Determination (NCD) 
Urine Culture, Bacterial 190.12. 
 
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 state that for Acute Myelogenous Leukemia (AML), Genomic Sequential Analysis Panel will be 
considered reasonable and necessary in the evaluation of blood or bone marrow samples in the following 
  
  clinical circumstances: 
 
   - Newly diagnosed patients with AML who are undergoing induction therapy, and who are suitable 
candidates for post-induction transplantation or consolidation therapy at the time of testing, and meet one of the 
following cytogenetic criteria: 
       -- normal karyotype 
       -- core binding factor 
   - Previously diagnosed patients with AML, who have not responded to induction chemotherapy, or who have 
progressed following induction. The patient must be a candidate for transplantation at the time of the testing. 
   - Patients with AML, who have responded to treatment, either chemotherapy or transplantation, with 
evidence of relapse. 
 
For Myelodysplastic Syndromes (MDS), Genomic Sequential Analysis Panel will be considered reasonable and 
necessary in the evaluation of blood or bone marrow samples in the following clinical circumstances: 
 
   - Patients with clinical signs or symptoms of myelodysplastic syndromes (MDS) or 
myelodysplastic/myeloproliferative overlap syndromes (MDS/MPN), in whom clinical, laboratory, and 
pathologic assessment are nondiagnostic. 
   - Newly diagnosed MDS or MDS/MPN patients either 
       -- stratified by the IPSS or IPSS-R as intermediate risk, or 
       -- in MDS with ringed sideroblasts/RARS.  
 
Limitations 
 
   - Repeat Genomic Sequential Analysis Panel testing is not reasonable and necessary in MDS after initial 
diagnosis and risk stratification. 
 
  
For Myeloproliferative Neoplasms (MPN), Genomic Sequential Analysis Panel will be considered reasonable 
and necessary in the evaluation of blood or bone marrow samples in the following circumstances: 
 
    - Diagnosis: Clinical signs or symptoms of myeloproliferative neoplasm (MPN) or 
myelodysplastic/myeloproliferative overlap syndromes (MDS/MPN) when 
       -- clinical, laboratory, and pathologic assessment are nondiagnostic; and 
       -- CML excluded (BCR-ABL1 negative)1,2 
   - Risk Stratification: Newly diagnosed PMF not already classified as high-risk by Dynamic International 
Prognostic Scoring System (DIPSS) Plus1,3,4 
   - Monitoring: Higher-risk MF (INT-1, INT-2, High-Risk) with progression on therapy. 
 
You can find this rule in the Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid 
Diseases (L37606). 
 
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 there is no further payment for oxygen equipment during the 5-year reasonable useful 
lifetime (RUL) of the equipment after 36 rental payments have been made. If use of portable equipment 
(E0431, E0433, E0434, E1392, K0738) begins after the use of stationary equipment begins, payment for the 
portable equipment can continue after payment for the stationary equipment ends until 36 rental payments have 
been made for the portable equipment. The supplier who provided the equipment during the 36th rental month 
is required to continue to provide the equipment, accessories, contents (if applicable), maintenance, and repair 
of the oxygen equipment during the 5-year reasonable useful lifetime of the equipment. You can find this rule 
in the Local Coverage Determination and Article for Oxygen and Oxygen Equipment, L33797 and A52514. 
 
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 80-81 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 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 63 to 64 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 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 page 35 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 skin sealants or barriers (A6250) are examples of wound-care items which are non-covered 
under the surgical dressing benefit because they do not meet the statutory definition of a dressing. You can find 
this information in the Local Coverage Article: Surgical Dressings - Policy Article (A54563). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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 Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
If the base power mobility device is not covered, related accessories will also be denied. You can find this rule 
in Local Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
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 claims for ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be 
denied as incorrect coding. You can find this rule in the Local Coverage Determination (LCD) for Respiratory 
Assist Devices (L33800). 
 
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 cerebrovascular arterial studies may be considered medically necessary if one or more of the 
following signs and symptoms are present: 
 
    Asymptomatic or symptomatic cervical bruits; 
    Amaurosis fugax; 
    Focal cerebral or ocular transient ischemic attacks (including but not limited to): 
        localizing symptoms, e.g., sensory loss; and/or 
        weakness of one side of the face; and/or 
        slurred speech; and/or 
        weakness of a limb; 
    Syncope that is strongly suggestive of vertebrobasilar or bilateral carotid artery disease in etiology, as 
suggested by medical history; 
    Recent history of a previous neurologic or cerebrovascular event; 
    Before major cardiac and vascular surgery when a bruit is noted or there is a history of previous neurologic 
or cerebrovascular event; 
    After carotid endarterectomy (outside the global period), or follow-up of previously documented stenoses; 
    Pulsatile neck mass; 
    Evaluation of blunt or penetrating neck trauma; 
    Ocular microembolism (optic nerve/retinal arterial-Hollenhorst plaques/ocular); 
 
You can find this information in the Local Coverage Determination (LCD) for Non-Invasive Vascular Studies 
(L34045). 
 
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 parenteral nutrition is covered for a beneficiary with permanent, severe pathology of the 
alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength 
commensurate with the beneficiary's general condition. The beneficiary must have a permanent impairment. 
Permanence does not require a determination that there is no possibility that the beneficiary's condition may 
improve sometime in the future. If the judgment of the attending physician, substantiated in the medical record, 
is that the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is 
considered met. Parenteral nutrition will be denied as non-covered in situations involving temporary 
impairments. The beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands 
which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a 
motility disorder and impairs the ability of nutrients to be transported through the GI system. There must be 
objective evidence supporting the clinical diagnosis. Parenteral nutrition is noncovered for the beneficiary with 
a functioning gastrointestinal tract whose need for Parenteral nutrition is only due to any of the following 
conditions: 
 
-Swallowing disorder 
-Temporary defect in gastric emptying such as a metabolic or electrolyte disorder 
-Psychological disorder impairing food intake such as depression 
-Metabolic disorder inducing anorexia such as cancer 
-Physical disorder impairing food intake such as the dyspnea of severe pulmonary or cardiac disease 
-Side effect of a medication 
-Renal failure and/or dialysis 
 
You can find this rule in Local Coverage Article: Parenteral Nutrition - Policy Article (A52515) - Effective 
January 1, 2017. 
 
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 where electric nerve stimulation is employed to treat motor function disorders, no 
reimbursement may be made for the stimulator or for the services related to its implantation since this treatment 
cannot be considered reasonable and necessary. 
 
You can find this information in the National Coverage Determination (NCD) Treatment of Motor Function 
Disorders with Electric Nerve Stimulation 160.2. 
 
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 the Correct Coding Initiative was developed to promote correct coding and to control 
improper coding leading to inappropriate payment in Part B claims. An add-on code is eligible for payment 
only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on 
code is not eligible for payment if it is the only procedure reported by a practitioner. The only exception is as 
follows:  
 
For the same date of service only one physician of the same specialty in the group practice may report code 
99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care 
services with CPT code 99292. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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. on page 61 of 
the 2023 Evidence of Coverage (EOC).