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 will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
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 certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested item or service but is limited to 3 of (D2710-D2792, D6210-D6792) every calendar year. You can 
find this information on pages 58-60, and 105-125 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 radiology and other diagnostic services furnished to hospital outpatients are paid under the 
Outpatient Prospective Payment System (OPPS) to the hospital. You can find this rule in the Medicare Claims 
Processing Manual, Chapter 13, Section 20.2.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 32-33 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 that both Initial Hospital Care and Subsequent Hospital Care codes are per diem services and 
may be reported only once per day by the same physician or physicians of the same specialty from the same 
group practice. You can find this rule in the Center for Medicare Services (CMS) Publication 100-04, Medicare 
Claims Processing Manual, Chapter 12, Section 30.6.9. 
 
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 to qualify for a knee orthosis, our Medicare guidelines require that the member have one of 
the following: (1) recent injury to or a surgical procedure on the knee(s); or (2) able to ambulate with 
documented knee instability by the treating physician due to certain medical conditions. You can find this 
information in the Local Coverage Determination (LCD) L33318  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 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 34-35 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 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 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. 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 visits by the same physician on the same day as a minor surgery or endoscopy are included in 
the payment for the procedure, unless a significant, separately identifiable service is also performed. Modifier 
"-25" is used to facilitate billing of evaluation and management services on the day of a procedure for which 
separate payment may be made. It is used to report a significant, separately identifiable evaluation and 
management service by same physician on the day of a procedure. 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, Sections 40.1(C) and 40.2.A(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 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 A/B Medicare Administrative Contractors (MACs) (B) may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological 
services to the hospital, e.g., administrative or supervisory services, and for provider services needed to 
produce the radiology service, is made by the A/B MAC (A) to the hospital as a provider service. A/B MACs 
(A) include the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in 
the prospective payment system (PPS) payment to hospitals. Hospital bundling rules exclude payment to 
suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay. The TC of radiology and 
other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment 
System (OPPS) to the hospital. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual Publication 100-04, Medicare Claims Processing Manual Chapter 13, Section 20.2.1. 
 
The rules say that payment may be made under the physician fee schedule for the professional component of 
physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital 
physicians or by independent laboratories, if they qualify as the re-assignee for the physician service. You can 
find this rule in the Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual, Chapter 
12, Section 60. 
 
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 drug testing is indicated when:

1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical history. 
3. This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids.

You can find this information in Local Coverage Determination (LCD): Drug Testing (L34645).

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 both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary for osteoporotic conditions when all of the following criteria are 
met: 

1. Acute or subacute osteoporotic vertebral compression fracture (VCF) based on symptom onset, and 
documented by recent (within 30 days) advanced imaging and 
2. The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
visual Analog Scale [VAS] pain score  8) or is non-hospitalized with moderate to severe pain (NRS or 
VAS  5) despite optimal non-surgical management (NSM) with one of the following: 
a. Worsening pain or 
b. Stable to improved pain when 2 or more of the following are present: 
- Progression of vertebral body height loss 
- >25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning 
- Steroid-induced fractures 
- Reinforcement or stabilization of vertebral body prior to surgery 

You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38213). 
 
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 if one laboratory procedure evaluates multiple genes using a next generation sequencing 
(NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis 
code. If no code accurately describes the procedure performed, the laboratory may report Current Procedural 
Terminology (CPT) code 81479 (Unlisted molecular pathology procedure) with one unit of service. You can 
find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, National 
Correct Coding Initiative (NCCI) Manual, Chapter 10, Section F(8). 
 
The rules say that a bacterial urine culture is a laboratory procedure performed on a urine specimen to establish 
the probable etiology of a presumed urinary tract infection (UTI). It is common practice to do a urinalysis prior 
to a urine culture. A urine culture may also be used as part of the evaluation and management of another related 
condition. 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 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 in Chapter 4 on page 46 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 Health Insurance Prospective Payment System (HIPPS) codes are alpha-numeric codes of 
five digits. Each code contains intelligence, with certain positions of the code indicating the case mix group 
itself, and other positions providing additional information. The additional information varies among HIPPS 
codes pertaining to different payment systems, but often provides information about the clinical assessment 
used to arrive at the code. Which positions of the code carry the case mix group information may also vary by 
payment systems. Providers must use these HIPPS codes to report SNF claims to Medicare insurers. You can 
find this rule at Centers for Medicare and Medicaid Services (CMS), CMS Division of Institutional Claims 
Processing, Definition and Uses of Health Insurance Prospective Payment System Codes (HIPPS Codes), dated 
April 4, 2022. 
 
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 iliac angiography or lower extremity angiography performed at the time of a 
different interventional procedure (for example, cardiac catheterization with coronary angiography) 
 
Diagnostic lower extremity angiography performed at the time of an interventional procedure is separately 
reportable if at least one indication for medical necessity for a stand-alone lower extremity is met AND one of 
the following is also met: 
 
    No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the 
decision to intervene is based on the diagnostic study, or 
    A prior study is available, but as documented in the medical record: 
        the patients condition with respect to the clinical indication has changed since the prior study; or 
        there is inadequate visualization of the anatomy or pathology; or 
        there is a clinical change during the interventional procedure that requires new evaluation outside the 
target area of intervention. 
 
III. Indications for stand-alone iliac or lower extremity angiography must be documented by pre-procedure 
clinical assessment. This assessment should include the following: 
 
    Documentation that an invasive intervention is planned, AND 
    Documentation that a prior non-invasive study was completed and indicates further study is needed by 
angiography for the planned intervention, AND 
    Documentation of one of the following conditions: arterial embolism, acute or chronic ischemia, peripheral 
vascular disease (includes claudication), or aneurysm. 
 
You can find this information in the Local Coverage Determination (LCD) Aortography and peripheral 
angiography L36767. 
 
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 because many radiological oncologists believe that proton beam therapy is a legitimate 
treatment option in certain circumstances where 3-dimensional conformal or intensity modulated radiation 
therapy (IMRT) is deemed medically necessary, proton beam therapy will be considered as medically 
reasonable and necessary for certain other conditions not listed above, as long as the following criteria are met: 
- Either #1, #2, or #3 must be present and 
- Either #4 or #5 must be present and 
- #6 must always be present. 
1. When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the 
tumor with other indicated methods 
2. When there is a reason to believe that doses generally thought to be above the level otherwise 
attainable with other methods might improve control rates 
3. In circumstances when the higher levels of precision associated with proton beam therapy as 
compared to other radiation methods are necessary, i.e., clinically relevant 
4. For the treatment of primary lesions, the intent of treatment must be curative 
5. For the treatment of metastatic lesions, there must be 
~ the expectation of a long-term benefit (greater than 2y) that could not have been attained 
with conventional therapy 
~ the expectation of a complete eradication of the metastatic lesion that could not have 
been safely accomplished with conventional therapy, as evidenced by a dosimetric 
advantage for proton beam radiotherapy over other forms of radiation therapy 
6. The patients record demonstrates why Proton beam radiotherapy is considered the treatment of 
choice for the individual patient. Specifically, the record must address the lower risk to normal 
tissue, the lower risk of disease recurrence, and the advantages of the treatment over IMRT or 3-
dimensional conformal Dosimetric evidence of reduced normal tissue toxicity and/or improved 
tumor control must be maintained. 
 
You can find these rules in Local Coverage Determination (LCD) Proton Beam Radiotherapy (L33937). 
 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. 
 
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17). 
 
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.