Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that an expandable controller can be covered when one or more of the following features are 
medically necessary: 
1. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head 
control, etc.) other than a standard proportional joystick. 
2. Non-proportional input devices (e.g., sip and puff, head array, etc.) 
3. The ability to operate 3 or more powered seating actuators through the drive control.  
4. A separate display (i.e., for alternate control devices) 
5. Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs 
drive control) 
6. An attendant control 
These rules can be found in Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
 
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 providers should bill the appropriate International Classification of Diseases (ICD-10) 
diagnosis code that represents laterality, if appropriate. You can find this information at Centers for Medicare 
and Medicaid Services, ICD-10 Official Guidelines for Coding and Reporting, Section B.13. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. You 
can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare 
Claims Processing Manual, Chapter 4, Section 10.4.C.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.
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 Maintenance Organizations (HMOs) may offer a Point of Service (POS) option as a 
mandatory or optional supplemental benefit. The POS benefit provides coverage for some plan-covered 
services outside of the HMOs network. The HMO plan may either require or waive prior authorization rules 
for obtaining POS services. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that because the Plan offers a Point of Service (POS) benefit, the Plan will cover services from 
either in-network or out-of-network providers. You can find this information on page 30 of the Plan's 2022 
EOC. 
 
The Plan contract also says that some services, including lab services, are covered only if the doctor or other 
provider gets approval in advance (sometimes called prior authorization). You can find this information on 
pages 39 and 66 of the Plan's 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 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 the explanation for use of a greater quantity of supplies than the amounts listed must be 
clearly documented in the beneficiarys medical record. If adequate documentation is not provided when 
requested, the excess quantities will be denied as not reasonable and necessary. You can find this rule in Local 
Coverage Determination (LCD) Ostomy Supplies L33828. 
 
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 this is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V 
Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR 
gene which encodes the 5,10-methylenetetrahydrofolate reductase enzyme. Genetic testing for these genes for 
all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-
covered except for pregnant patients. You can find this information in Medicare's Local Coverage 
Determination (LCD): MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, 
Factor II Prothrombin, and MTHFR) (L35984). 
 
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 an Excludes1 note indicates that the code excluded should never be used at the same time as 
the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a 
congenital form versus an acquired form of the same condition. You can find this rule at Centers for Medicare 
and Medicaid Services, ICD-10-CM Official Guidelines for Coding and Reporting. 
 
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 value code 85 is defined "County Where Service is Rendered." This code is required for 
home health claims to appropriately calculate county-based rural add-on payment amounts. You can find this 
rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-04, Medicare Claims 
Processing Transmittal 4106, Change Request 10782. 
 
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 an ambulance transport is covered to the nearest appropriate facility to obtain necessary 
diagnostic and/or therapeutic services. Only local transportation by ambulance is covered, and therefore, only 
mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more 
facilities that meet the destination requirements can treat the patient appropriately and the locality of each 
facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to 
any one of the facilities to which the beneficiary is taken is covered. 
 
The term "locality" with respect to ambulance service means the service area surrounding the institution to 
which individuals normally travel or are expected to travel to receive hospital or skilled nursing services. The 
MACs have the discretion to define locality in their service areas. 
 
The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital 
or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician 
or a physician specialist is available to provide the necessary care required to treat the patient's condition. The 
fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient 
does not warrant a finding that a closer institution does not have "appropriate facilities." Such a finding is 
warranted, however, if the beneficiary's condition requires a higher level of trauma care or other specialized 
service available only at the more distant hospital. An institution is also not considered an appropriate facility if 
there is no bed available. The contractor, however, will presume that there are beds available at the local 
institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time 
the ambulance service was provided.  
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3, 10.3.5, and 10.3.6. 
 
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 state that effective April 7, 2022, the Centers for Medicare & Medicaid Services (CMS) covers Food 
and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for the treatment of 
AD when furnished under coverage with evidence development (CED) for patients who have a clinical 
diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both with confirmed presence 
of amyloid beta pathology consistent with AD. Monoclonal antibodies directed against amyloid for the 
treatment of AD provided outside of an FDA-approved randomized controlled trial, CMS-approved studies, or 
studies supported by the National Institutes for Health (NIH), are nationally non-covered. You can find these 
rules in National Coverage Determination (NCD) Monoclonal Antibodies Directed Against Amyloid for the 
Treatment of Alzheimers Disease (AD) (200.3). 
 
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.
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 pages 73 to 74 of the Plans' 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).   
 
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 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 Grievance Manual, Section 50.12.1. 
 
The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as 
toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
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 some International Classification of Diseases (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, providers should assign separate codes for both the left and right side. If the side is not 
identified in the medical record, providers should assign the code for the unspecified side. You can find this 
rule at Centers for Medicare and Medicaid Services, ICD-10-CM Official Guidelines for Coding and 
Reporting, Section B.13. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that tests performed to measure the quality of a process do not provide information to diagnose 
or treat a patient illness or injury as defined in the Medicare benefit category. Therefore, the know error DNA 
Specimen Provenance Assay is a statutorily excluded test. This rule is found in Local Coverage Article Billing 
and Coding: MolDX: know error (A55172). 
 
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 test panel is a single test with multiple components and is characterized by a single unit of 
service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. This rule is found in Local Coverage Article 
Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification 
Testing (A58710). 
 
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 the treatment of individuals with spinal disorders, including pain, can be complex, and it is 
recommended that all individuals being considered for interventional spinal procedures undergo a thorough 
evaluation and be treated following development of a comprehensive care plan. 
 
Covered Indications 
1. Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the 
following three (3) requirements are met: 
- History, physical examination, and concordant radiological image-based diagnostic testing        
and supporting one of the following: 
- Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to central disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis; OR 
- Post-laminectomy syndrome 
- Acute herpes zoster associated pain 
 
You can find this information in the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain 
Management (L38994). 
 
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 sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-
frequency syndrome, and urinary retention. However, the following criteria must be met for coverage to be 
approved: 
 
1. The patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or 
surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can 
occur. 
 
2. Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with 
peripheral nerve involvement) which are associated with secondary manifestations of the above three 
indications are excluded. 
 
3. The patient must have had a successful test stimulation in order to support subsequent implantation. Before a 
patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through 
test stimulation. Improvement is measured through voiding diaries. 
 
4. The patient must be able to demonstrate adequate ability to record voiding diary data such that clinical 
results of the implant procedure can be properly evaluated. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Internet-Only Publication 100-02, 
Medicare National Coverage Determinations Manual Section 230.18. 
 
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 Current Procedural Terminology (CPT) Manual assigns CPT codes to organ- or disease-
oriented panels consisting of groups of specified tests. If all tests of a CPT-defined panel are performed, the 
provider/supplier shall bill the panel code instead of the individual components. You can find this information 
in the Centers for Medicare and Medicaid Services, Internet Only Manual, National Correct Coding Initiative 
(NCCI) Manual, Chapter 10. 
 
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.