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 417.414. 
 
The rules state that: 
Visual Evoked Potentials or Responses (VEPs/VERs) 
1. Confirm diagnosis of multiple sclerosis when clinical criteria are inconclusive 
2. Evaluate diseases of the optic nerve, such as: 
a. Optic neuritis 
b. Ischemic optic neuropathy 
c. Toxic amblyopias 
d. Nutritional amblyopias 
e. Neoplasms compressing the anterior visual pathways 
f. Optic nerve injury or atrophy 
g. Malingering/functional vision loss (to rule out) 
3. Monitor the visual system during optic nerve (or related) surgery (monitoring of short latency evoked 
potential studies). 
You can find this rule at the Medicare Local Coverage Determination (LCD) L36831: Visual 
Electrophysiology Testing. 
 
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 heavy duty and bariatric devices are included in the codes for pressure reducing support 
surfaces: E0193, E0277, E0371, E0372 and E0373. 
 
Code E0277 describes a powered pressure reducing mattress (alternating pressure, low air loss, or powered 
flotation without low air loss) which is characterized by all of the following: 
 
An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface 
pressure throughout the mattress, and 
Inflated cell height of the air cells through which air is being circulated is 5 inches or greater, and 
Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for 
alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent 
bottoming out, and 
A surface designed to reduce friction and shear, and 
Can be placed directly on a hospital bed frame. 
Either alternating pressure mattresses or low air loss mattresses are coded using code E0277. 
 
Products containing multiple components are categorized according to the clinically predominant component 
(usually the topmost layer of a multi-layer product). For example, a product with 3" powered air cells on top of 
a 3" foam base would be coded as a powered overlay (code E0181) not as a powered mattress (E0277). 
 
You can find these rules in the Local Coverage Article 
Pressure Reducing Support Surfaces - Group 2 - Policy Article A52490. 
 
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 $70 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page(s) 81 of the Plan's 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a repeat epidural steroid injection (ESI) when the first injection directly and significantly 
provided improvement of the condition being treated may be considered medically reasonable and necessary 
when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement 
in function measured from baseline using SAME scale for at least three months. You can find this information 
in the Local Coverage Determination (LCD) for Epidural Steroid Injections for Pain Management (L39242). 
 
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 effective 1/1/2014 (v15.0), the submission of certain skin substitute application procedures 
requires the reporting of a skin substitute product for the same day. Certain skin substitute application 
procedures and skin substitute products are divided into two lists based on high or low cost. Claims containing 
a high cost skin substitute application procedure without any of the high cost skin substitute product codes, and 
conversely any low cost skin substitute application procedure without a low cost skin substitute product code 
for the same day, are returned to the provider (edit 87). (See the DATA_HCPCS table within the data files for 
skin substitute products flagged as either high or low cost). 
Effective 10/1/2015 (v16.3), if a skin substitute product code is present with line item action flag value of 2 
representing an external line item denial, the line is not ignored by the IOCE for the purposes of applying edit 
87. If the denied skin substitute product is on the list of skin substitute products and the skin substitute 
application procedure is also present, edit 87 is not returned. You can find this rule in the Integrated Outpatient 
Code Editor (OCE) (IOCE) CMS Specifications V24.1, Effective April 1, 2023, Section 5.13. 
 
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 say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and 
equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, 
communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-
saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency 
medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You 
can find this rule at 42 CFR Section 410.41(a). 
 
The rules say that plans may offer a supplemental benefit to provide transport not covered by original 
Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the 
doctors office. The transport must be arranged or directly provided by the health plan. The transport may not 
be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit 
covers up to 12 one-way trips to in-network approved locations. You can find this information on page 108 of 
the Plans 2023 Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 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 and cover any medically necessary covered benefit of the plan provider network, but at in-network 
cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet a member's medical 
needs. You can find this rule at 42 CFR Section 422.112(a)(1)(iii). 
 
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 you can choose to receive care from out-of-network providers. However, please note 
providers that do not contract with us are under no obligation to treat you, except in emergency situations. Our 
plan will cover services from either network or out-of-network providers, as long as the services are covered 
benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs 
for your covered services may be higher. The contract also says that you do not need to get a referral or prior 
authorization when you get care from out-of-network providers. You can find this information on pages 42 and 
43 of the Plan's 2023 Evidence of Coverage. 
 
The contract also says that you must pay a $50 copayment per day for therapy visits rendered by an out-of-
network provider. You can find this information on page 98 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 there are certain diagnosis codes which support the medical necessity of code 81340. Any 
codes which are not listed are considered not medically necessary for code 81340. You can find this 
information in the Centers for Medicare and Medicaid Services, Local Coverage Article (LCA): Billing and 
Coding: Molecular Pathology Procedures (A56199). 
 
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 power operated vehicle (POV) is covered if the beneficiarys weight is less than or equal 
to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of 
the next lower weight class POV  i.e., a Heavy Duty POV is covered for a beneficiary weighing 285  450 
pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428  600 pounds. A K0800 power 
operated vehicle has a weight limit up to 300 pounds. You can find this rule in Local Coverage Determination 
(LCD) Power Mobility Devices (L33789). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
The rules say that certain data elements are required for home health services. Any claim with incomplete, 
missing, or invalid information for all of these elements may be returned as unprocessable. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare 
Claims Processing Manual, Chapter 1, Section 80.3.1. 
 
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 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 state that if an independent lab bills for services, the place where the sample was taken is reported as 
the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of 
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 26, Section 10.6. 
 
The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other 
supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two 
exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or 
outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You 
can find this information in the MLN Matters article number MM7631, Revised and Clarified Place of Service 
(POS) Coding Instructions. 
 
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 PTA of a single coronary artery is covered for patients for whom the likely alternative 
treatment is coronary bypass surgery and who exhibit the following characteristics: 
 Angina refractory to optimal medical management; 
 Objective evidence of myocardial ischemia; and 
 Lesions amenable to angioplasty. 
You can find this rule in the Center for Medicare and Medicaid Services (CMS) Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Section 20.7. 
 
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 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 page(s) 13-14 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 indications for surgical treatment and sclerotherapy: 
 
1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive 
therapy, and avoidance of prolonged immobility where appropriate, has failed, AND 
2. The patient is symptomatic and has 1, or more, of the following: 
    1. Pain, aching, cramping, burning, itching and/or swelling during activity or after prolonged          standing 
severe enough to impair mobility 
    2. Recurrent episodes of superficial phlebitis 
    3. Non-healing skin ulceration 
    4. Bleeding from a varicosity 
    5. Stasis dermatitis 
    6. Refractory dependent edema 
3 The treatment of spider veins/telangiectasis will be considered medically necessary only if there is associated 
hemorrhage 
 
You can find this information in the Local Coverage Determination (LCD) Treatment of Varicose Veins of the 
Lower Extremities L34536. 
 
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 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). 
 
The rules say that abdominal lipectomy/panniculectomy are surgical removal of hanging excessive fat and skin 
in a transverse or vertical wedge from the abdomen but does not include muscle plication or flap elevation. 
This surgery is considered reconstructive when it is performed to alleviate such complicating factors as 
inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis 
(dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing). This procedure may 
be done after weight loss surgery where there has been a great deal of weight loss with significant skin 
redundancy with complicating factors as above. 
 
Abdominal lipectomy/panniculectomy is considered medically reasonable and necessary when the pannus or 
panniculus hangs below the level of the symphysis pubis causing one or more of the following conditions: 
- Chronic intertrigo that consistently remains refractory to appropriate medical therapy (e.g., topical 
antifungals, corticosteroids, antibiotics) over a period of three months. 
- Difficulty walking or functional impairment in activities of daily living. 
 
If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted 
above, there should be evidence that the patient has maintained a stable weight for at least six months. For 
patients whose weight loss is the result of bariatric surgery, abdominal lipectomy/panniculectomy should not be 
performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the 
most recent six months. You can find this information in Local Coverage Determination (LCD): Cosmetic and 
Reconstructive Surgery (L35090). 
 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 the face-to-face encounter must be conducted within six (6) months prior to the order date for 
the power mobility device. You can find this rule in the Local Coverage Determination (LCD): Power Mobility 
Devices (L33789). 
 
The rules say that the order for the base item may only be written after the completion of the face-to-face 
encounter requirements. The treating practitioner who completes the face-to-face requirements must be the 
same practitioner who writes the order/prescription for the power mobility device. You can find this rule in the 
Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.