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.  Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to:   1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;   2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and   3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL.  You can find this rule at 42 CFR Section 411.15(b).   Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).  The rules say that providers 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).  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 health Plan contract says that an eye exam and one pair of eyeglasses (or contact lenses) are covered for people after cataract surgery. Routine eye examinations are covered once per year. You can find this information on pages 104-105 and 112 of the Plan's 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that providers 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 two repeat procedure modifiers are applicable for hospital use: &#8722; Modifier -76 is used to indicate that the same physician repeated a procedure or service in a separate operative session on the same day. &#8722; Modifier -77 is used to indicate that another physician repeated a procedure or service in a separate operative session on the same day. If there is a question regarding who the ordering physician was and whether or not the same physician ordered the second procedure, the code selected is based on whether or not the physician performing the procedure is the same. The procedure must be the same procedure. It is listed once and then listed again with the appropriate modifier. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.5.  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. The health plan contract says that Hyalgan is subject to step therapy. The preferred agents are Orthovisc and Monovisc. For a step therapy exception to be granted, the provider needs to tell the plan if the member is already using the requested agent; OR, why the preferred agent(s) would be contraindicated. You can find this rule in the plan's step therapy policy.
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).  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 crowns, periodontal scaling and root planing, and implants are covered benefits
when medically reasonable and necessary. You can find this information on pages 61, 62, and 90 of the Plan's
2021 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 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).  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 1-6 of the Plan's 2020 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 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 state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B.  Invalid or incorrect POS codes will be denied and returned to the provider. If an independent lab bills for services, the place where the sample was taken is reported as the POS. An independent laboratory taking a sample in its laboratory shows "81" as place of service.  You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 26, Section 10.6.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.      The rules say that 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 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 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 all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. You can find this rule in 42 CFR, Section 410.32.  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 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 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 Guidance Manual, Section 50.12.1.  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 Medicare has re-affirmed non-coverage for procedure codes 0012M and 0013M for Cxbladder. This information can be found in Local Coverage Determination (LCD): Biomarkers for Oncology (L35396).  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 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 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 Medicare Program Integrity Manual Chapter 3 ? 3.3.2.1.  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. The contract says covered, non-routine dental care is limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. You can find this information on pages 4-53 to 4-54 of the Plan's 2021 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 a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone. A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met: 1. The beneficiary has lymphedema of an extremity as defined above   2. The coverage criteria for an E0650 or E0651 are met   3. The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial.   You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - Effective January 1, 2020.   The rules say that the only time that a segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) would be covered is when the individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a non-segmented device in conjunction with a segmented appliance or a segmented compression device without manual control of pressure in each chamber.   You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - Effective January 1, 2020.   The rules say that a four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 or E0651 is required for coverage of E0652. You can find this rule in Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) - Effective January 1, 2020.  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.  Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to:   1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;  2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL; and  3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with an IOL.  You can find this rule at 42 CFR Section 411.15(b).   Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 CFR Section 411.15(c).  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 43 of the Plan's 2021 Evidence of Coverage.   The Plan contract says that 1 routine eye exam is covered per calendar year. The eye exam will include refraction and dilation. In-network you pay $0. You can find this information on page 85 of the Plan's 2021 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 Correct Coding Initiative was developed to promote correct coding and to control improper coding leading to inappropriate payment in Part B claims. The Coding Policy Manual also explains what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code pairs that should not be reported together. Medicare Administrative Contractors (MACs) subject all line items for the same beneficiary, same National Provider Identifier (NPI), and same date of service to National Correct Coding Initiative (NCCI) edits. The National Correct Coding Initiative (NCCI) File Formats continue to include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit file. This indicator determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the code pair to bypass the edit. 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 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. The only exception is as follows:   For the same date of service only one physician of the same specialty in the group practice may report code 99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care services with CPT code 99292.  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.  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.