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 follow-up polysomnography or sleep studies are not routinely indicated for patients treated 
with continuous positive airway pressure (CPAP) whose symptoms continue to be resolved with CPAP 
treatment. Follow-up polysomnography studies may be indicated, however, for the following conditions: 
- After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related 
breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure; 
 
- After substantial weight gain has occurred in patients previously treated with CPAP successfully, 
who are again symptomatic despite the continued use of CPAP, to ascertain whether pressure 
adjustments are needed; or 
 
- When clinical response is insufficient or when symptoms return despite a good initial response to 
treatment with CPAP. 
You can find this information in the Local Coverage Determination (LCD) for Outpatient Sleep Studies 
(L35050). 
 
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 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 Plan 
contract says preventive dental services, including oral exams, x-rays and cleanings, are covered. The contract 
also says that Medicare-covered comprehensive dental services are covered only following reconstruction of 
the jaw, accidental injury, or extractions in preparation for radiation treatment. You can find this information 
on page 71 of the Plans 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 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 some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes 
for both the left and right side. If the side is not identified in the medical record, assign the code for the 
unspecified side. 
 
When a patient has a bilateral condition and each side is treated during separate encounters, assign the 
"bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. 
For the second encounter for treatment after one side has previously been treated and the condition no longer 
exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., 
cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for 
the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the 
treatment on the first side did not completely resolve the condition, then the bilateral code would still be 
appropriate. 
 
When laterality is not documented by the patients provider, code assignment for the affected side may be 
based on medical record documentation from other clinicians. If there is conflicting medical record 
documentation regarding the affected side, the patients attending provider should be queried for clarification. 
Codes for unspecified side should rarely be used, such as when the documentation in the record is 
insufficient to determine the affected side and it is not possible to obtain clarification. 
You can find these rules in the ICD-10-CM Official Guidelines for Coding and Reporting, FY 2023. 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules 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 also say that if a physician advises his/her own patient to go to an emergency department (ED) of a 
hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to 
evaluate the patient and to advise the ED physician as to whether the patient should be admitted to the hospital 
or be sent home, the physicians should bill as follows: 
 
   - If the patient is admitted to the hospital by the patient's personal physician, then the patient's regular 
physician should bill only the appropriate level of the initial hospital care (codes 99221 - 99223) because all 
evaluation and management services provided by that physician in conjunction with that admission are 
considered part of the initial hospital care when performed on the same date as the admission. The ED 
physician who saw the patient in the emergency department should bill the appropriate level of the ED codes. 
   - If the ED physician, based on the advice of the patient's personal physician who came to the emergency 
department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of 
emergency department service. The patient's personal physician should also bill the level of emergency 
department code that describes the service he or she provided in the emergency department. If the patient's 
personal physician does not come to the hospital to see the patient, but only advises the emergency department 
physician by telephone, then the patient's personal physician may not bill. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Chapter 12, 
Section 30.6.11 (E). 
 
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 purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of 
Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face-to-face 
service. For example, if the physician's face-to-face encounter with a patient occurs in the office, the correct 
POS code on the claim, in general, reflects the 2-digit POS code 11 for office. In these instances, the 2-digit 
POS code (Item 24B on the claim Form CMS-1500) will match the address and ZIP entered in the service 
location (Item 32 on the 1500 Form) - the physical/geographical location of the physician. However, there are 
two exceptions to this general rule - these are for a service rendered to a patient who is a registered inpatient or 
an outpatient of a hospital. In these cases, the correct POS code -- regardless of where the face-to-face service 
occurs -- is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate 
outpatient hospital POS code (at a minimum POS code 22) as discussed in section 10.5 of this chapter. So, if in 
the above example, the patient seen in the physician's office is actually an inpatient of the hospital, POS code 
21, for inpatient hospital, is correct. In this example, the POS code reflects a different setting than the address 
and ZIP code of the practice location (the physician's office). 
 
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 $30 copayment for in-network non-radiological diagnostic tests. You 
can find this information on pages 4-41 to 4-47 of the Plan's 2022 Evidence of Coverage (EOC).  
 
The Plan contract says that enrollees must pay a $125 copayment for in-network radiological diagnostic tests. 
You can find this information on pages 4-41 to 4-47 of the Plans 2022 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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that a reduction mammaplasty will be considered medically reasonable and necessary when 
performed: 
1. To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy when: 
 
A. The surgeon's estimate of breast size/weight/volume to be removed is proportional to the 
body surface area (BSA) per the Schnur scale
5 
per breast to relieve symptoms. 
B. There are signs or symptoms resulting from the enlarged breasts (macromastia) that have not 
responded adequately to non-surgical interventions. 
i. Symptoms are refractory to appropriately fitted supporting garments, or following 
unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction 
therapy at the site of the absent breast. 
 
ii. Dermatologic signs or symptoms are refractory to or recurrent following a completed 
course of medical management. 
a. Intertriginous maceration, discoloration, chronic or recurrent infection of the 
inframammary skin refractory to dermatologic treatment measures. 
 
iii. There is back pain from macromastia, unrelieved by: 
a. Conservative analgesia. b. Supportive measures (custom garment, etc.). 
c. Physical therapy. 
iv. There is shoulder grooving to a depth greater than 1 cm with skin irritation or 
darkening by supporting garment (bra strap).  
v. There are optimally managed significant arthritic changes in the cervical or upper 
thoracic spine, with persistent symptoms or significant restriction of activity. 
vi. The macromastia is not due to an active endocrine, pharmaceutical or metabolic 
process. 
      OR 
1. To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after 
cancer surgery. Note: either the involved breast or contralateral breast may be treated to achieve 
symmetry. 
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 an expandable controller is capable of accommodating one or more of the following 
additional functions: 
 
-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
-Non-proportional input devices (e.g., sip and puff, head array, etc.) 
-Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
 
-A separate display (i.e., for alternate control devices) 
-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control) 
-An attendant control 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that code E2311 describes an electronic component that allows 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 Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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 state that A physician who is writing prescriptions for medications to treat chronic pain can manage a 
patient better if the physician knows whether the patient is consuming another medication or substance, which 
could suggest the possibility of SUD or lead to drug-drug interactions. Additionally, UDT may help the 
physician monitor for medication adherence, efficacy, side effects, and patient safety in general. 
 
Criteria to establish medical necessity for drug testing must be based on patient-specific elements identified 
during the clinical assessment, and documented by the clinician in the patients medical record and minimally 
include the following elements: 
- Patient history, physical examination and previous laboratory findings; 
- Current treatment plan; 
- Prescribed medication(s); and 
- Risk assessment plan. 
 
Ongoing testing may be medically reasonable and necessary based on the patient history, clinical assessment, 
including medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, 
indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect 
or behavioral pattern. 
 
You can find this information in the Local Coverage Determination (LCD): Controlled Substance Monitoring 
and Drugs of Abuse Testing (L35006). 
 
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 page 135 of the 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, for procedures that do not usually require anesthesia services, MAC could be covered when 
the patients condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia 
in addition to the physician performing the procedure and is so documented in the patients medical record. 
The presence of an underlying condition alone may not be sufficient evidence that MAC is necessary. The 
medical condition must be significant enough to impact on the need to provide MAC such as the patient being 
on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily 
sufficient. You can find this rule at Local Coverage Determination (LCD) L35049: Monitored Anesthesia Care 
(eff. 10/17/19). 
 
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 definitive urine drug testing (UDT) is reasonable and necessary for the following 
circumstances: 
 
1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
2. Definitively identify specific drugs in a large family of drugs; 
3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., 
discontinuation of THC use according to a treatment plan); 
5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
6. Rule out an error as the cause of a presumptive UDT result; 
7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, 
medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. 
The clinicians rationale for the definitive UDT and the tests ordered must be documented in the patients 
medical record. You can find this rule in the Local Coverage Determination (LCD): Lab: Controlled Substance 
Monitoring and Drugs of Abuse Testing (L35724). 
 
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.