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 no payment may be made for the implantation of dorsal column or depth brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
  
   The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with 
chronic intractable pain; 
 With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient; 
 Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. (Such screening must include psychological, as well as physical evaluation); 
 All the facilities, equipment, and professional and support personnel required for the proper diagnosis, 
treatment training, and follow up of the patient (including that required to satisfy item c) must be 
available; and 
 Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
You can find this rule in the Center for Medicare Services (CMS) Publication 100-03, Medicare National 
Coverage Determination (NCD) Manual, Section 160.7. 
 
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 urine cultures are only covered when a patient's urinalysis is abnormal suggesting urinary 
tract infection, for example, abnormal microscopic (hematuria, pyuria, bacteriuria); abnormal biochemical 
urinalysis (positive leukocyte esterase, nitrite, protein, blood); a Gram's stain positive for microorganisms; 
positive bacteriuria screen by a non-culture technique; or other significant abnormality of a urinalysis. While it 
is not essential to evaluate a urine specimen by one of these methods before a urine culture is performed, 
certain clinical presentations with highly suggestive signs and symptoms may lend themselves to an antecedent 
urinalysis procedure where follow-up culture depends upon an initial positive or abnormal test result. You can 
find this information in the 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 say that abdominal/visceral non-invasive vascular studies are indicated in the evaluation and/or 
management of vascular disease along with, the narrowing or blockage of arteries that supply blood to the 
abdomen including intestines (mesenteric vascular disease), pelvic and scrotal contents, and/or retroperitoneal 
organs including the kidneys (renal vascular disease). The indications for these studies are: 
  
1. Uncontrolled hypertension. 
2. Stenosis of visceral artery (atherosclerotic, fibromuscular dysplasia, vasculitis, functional). 
3. Aneurysm of visceral artery. 
4. Portal hypertension, with or without ascites. 
5. Cirrhosis of the liver. 
6. Venous embolism, hemorrhage, infection, and/or thrombosis of visceral vein (renal, hepatic, mesenteric, 
portal or splenic). 
7. Stenosis of visceral vein (renal, hepatic, mesenteric, portal or splenic). 
8. Complications of internal (biological) (synthetic) prosthetic device implant and/or graft. 
9. Complications in abdominal organ or tissue transplant. 
10. Pain or swelling of scrotal contents which may be a result of suspected obstruction in arterial inflow or 
venous outflow to testicles or related structure. 
11. Torsion of the spermatic cord; acute epididymitis or epididymoorchitis; or torsion of the testicular 
appendages. 
12. Hypertension and normotensive renovascular disease with impaired renal function which could be acute 
kidney failure, chronic kidney disease, end stage renal disease, or other vascular disorders of the kidneys. 
13. Pain or swelling of the female genital organs which may be the result of torsion of the ovaries, ovarian 
pedicle, or fallopian tube. 
14. Trauma to the abdominal, retroperitoneal and/or pelvic organs, arteries, and /or veins. 
 You can find this information in the Local Coverage Determination (LCD) for Non-Invasive Abdominal / 
Visceral Vascular Studies (L35755). 
 
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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet 
joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet all the 
following criteria: 
 
Initial thermal RFA: 
 
a.   After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each 
one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used) AND 
 
b.   Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary 
provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months 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 
 
You can find this information in Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38841). 
 
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 only the following codes should be billed for Cardiovascular Disease Screening: code 
80061 (Lipid panel) which includes codes: 82465 (Cholesterol, serum or whole blood, total), 83718 
(Lipoprotein, direct measurement; high density cholesterol), and/or 84478 (Triglycerides). This rule is found in 
the Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services, Section 100.1 
 
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 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 when a patient is admitted for observation care and then is discharged on a different calendar 
date, the physician shall report Initial Observation Care, from CPT code range 99218  99220, and CPT 
observation care discharge CPT code 99217. When a patient receives observation care for a minimum of 8 
hours, but less than 24 hours, and is discharged on the same calendar date, Observation or Inpatient Care 
Services (Including Admission and Discharge Services) from CPT code range 99234  99236 shall be 
reported. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8. 
 
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on pages 41 and 45 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 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 in Chapter 3 on pages 30-35 of 
the Plan's 2022 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers should bill CPT code 67028 for the intravitreal injections, in addition to the drug(s) 
utilized. The appropriate site modifier (RT, LT, or 50) must be appended to CPT code 67028 to indicate if the 
service was performed unilaterally (RT or LT) or bilaterally (50). You can find this information in Medicare's 
Local Coverage Article Billing and Coding Billing and Coding: Vascular Endothelial Growth Factor Inhibitors 
for the Treatment of Ophthalmological Diseases (A56716). 
 
The rules say that when treatment for complications requires a return trip to the operating room, physicians 
must bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, 
use the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for the 
original surgery is not used except when the identical procedure is repeated. In addition to the CPT code, 
physicians use CPT modifier -78 for these return trips (return to the operating room for a related procedure 
during a postoperative period.) The physician may also need to indicate that another procedure was performed 
during the postoperative period of the initial procedure. When this subsequent procedure is related to the first 
procedure and requires the use of the operating room, this circumstance may be reported by adding the 
modifier -78 to the related procedure. Modifier -58 was established to facilitate billing of staged or related 
surgical procedures done during the postoperative period of the first procedure. This modifier is not used 
to report the treatment of a problem that requires a return to the operating room. The physician may need to 
indicate that the performance of a procedure or service during the postoperative period was a. Planned 
prospectively or at the time of the original procedure, b. More extensive than the original procedure; or c. For 
therapy following a diagnostic surgical procedure. These circumstances may be reported by adding modifier -
58 to the staged procedure. A new postoperative period begins when the next procedure in the series is billed. 
Modifier -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. A new postoperative period begins when the unrelated procedure is 
billed. You can find this information in the Medicare Claims Processing Manual Chapter 12, Section 40.2 - 
Billing Requirements for Global Surgeries. 
 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 Medicare does not pay for gym benefits. Gym benefits include exercise classes, such as Tai 
Chi, yoga, and dance classes. 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 Plan 
contract says that while you can get your care from an out-of-network provider, the provider must be eligible to 
participate in Medicare. The Plan contract also says that except for emergency care, we cannot pay a provider 
who has opted out of or been excluded or precluded from the Medicare Program. The Plan contract also says 
that if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full 
cost of the services you receive. You can find this information on page 3-4 of the Plan's 2022 Evidence of 
Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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). 
 
Medicare rules say that clinical laboratory tests include some services described as anatomic pathology 
services. CPT code 85060 is used only when a physician interprets an abnormal peripheral blood smear for a 
hospital inpatient or a hospital outpatient, and the hospital is responsible for the technical component. When an 
independent laboratory bills a physician interpretation of an abnormal peripheral blood smear, the service is 
considered a complete or global service, and is not billed under the CPT code 85060. A physician interpretation 
of an abnormal peripheral blood smear performed by an independent laboratory is considered a routine part of 
the ordered hematology service. You can find this information in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 
80.2. 
 
The rules say that a Professional/Technical Indicator of 8 identifies the professional component of clinical 
laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear 
for hospital inpatient. This applies to CPT codes 88141, 85060 and HCPCS code P3001-26. No TC billing is 
recognized because payment for the underlying clinical laboratory test is made to the hospital, generally 
through the PPS rate. No payment is recognized for CPT codes 88141, 85060 or HCPCS code P3001-26 
furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the 
clinical laboratory fee schedule payment for the clinical laboratory test. You can find this information in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 23, Section 50.6. 
 
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 one presumptive drug testing code may be billed once per patient per day as indicated by the 
code description and should only be billed at one unit regardless of the provider. 
 
One definitive drug testing code may be billed once per patient per day as indicated by the code description and 
should only be billed at one unit regardless of the provider. 
 
The documentation should support the medical necessity of the drug testing ordered and should support the 
clinical indicators that led to ordering the test. 
 
Documentation Requirements 
 
All documentation must be maintained in the patients medical record and available to the contractor upon 
request. Every page of the record must be legible and include appropriate patient identification information 
(e.g., complete name, dates of service(s)). The record must include the identity of the physician or non-
physician practitioner responsible for and providing the care to the patient. The submitted medical record 
should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the 
service performed. Medical record documentation (e.g., history and physical, progress notes) maintained by the 
ordering physician/treating physician must indicate the medical necessity for performing a drug test. All tests 
must be ordered in writing by the treating provider and all drugs/drug classes to be tested must be indicated in 
the order. If the provider of the service is other than the ordering/referring physician, that provider must 
maintain hard copy documentation of the lab results, along with copies of the ordering/referring physicians 
order for the drug test. The physician must include the clinical indication/medical necessity in the order for the drug test. You can find this information in Medicare's Local Coverage Article Billing and Coding Billing and 
Coding: Drug Testing (A56915). 
 
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 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 24 of the Plan's 2022 Schedule of Cost Sharing.