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 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 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 38 of the plan's 2020 
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 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). 
 
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 your deductible is $400. This is the amount you have to pay out-of-pocket before 
they will pay their share for your covered medical services. Until you have paid the deductible amount, you 
must pay the full cost of your covered services. You can find this information on page 39 of the plan's 2020 
Evidence of Coverage.  
 
The Plan contract says that there is a $0 copay for pacemaker testing services. Plan deductible applies. If you 
receive additional services, cost sharing for those services may apply. You can find this information on page 57 
of the plans 2020 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

Please note, the Local Coverage Determination and Articles (L36749, A57425, and A55624) are not binding in this case. The LCD and LCAs do not have jurisdiction where the services were provided. 

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 screening tests are excluded from coverage. The only exceptions are for the following services:

1. screening mammography, 
2. colorectal cancer screening tests,
3. screening pelvic exams, 
4. prostate cancer screening tests, 
5. glaucoma screening exams, 
6. ultrasound screening for abdominal aortic aneurysms (AAA), 
7. cardiovascular disease screening tests, 
8. diabetes screening tests, and
9. screening electrocardiograms
10. certain other testing recommended by the United States Preventive Services Task Force and approved by CMS
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64.

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 $275 copayment per day for days 1-5 and a $0 copayment after day 5 
for inpatient hospital care. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. You can find this information on 
page 86 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 ICD-10 
code that describes the services performed. You can find this rule in the Medicare National Correct Coding 
Initiative Manual, Chapter I(A). 
 
The rules say that modifier -51 is used to indicate a distinct procedural service. This code should not be 
appended to add-on codes. The contractor shall use the following remittance advice messages and associated 
codes when rejecting/denying claims under this policy. If a provider of service or supplier is required to submit 
a diagnosis in item 21 and either the diagnosis code is missing, incorrect or truncated; or a narrative diagnosis 
was not provided on an attachment.  
You can find this information in Medicare Claims Processing Manual Chapter 1 -General Billing 
Requirements. 
 
The Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics 
(NCHS) and the Department of Health and Human Services (DHHS), provides clear direction on the 
coding and sequencing of diagnosis codes.  
 
Utilizing the ICD-10-CM Official Guidelines for Coding and Reporting, this policy identifies diagnosis 
codes, which should never be billed as primary on a CMS-1500 claim form or its electronic equivalent. 
You can find this information in 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 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 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 8 of the plan's 2020 
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 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 SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes pontic 
(D6240). The Plan contract also says that pontics are not a covered benefit for molar teeth. You can find this 
information on pages 96 and 98 of the Plans 2019 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 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. The Plan 
contract says that chiropractic services only include manual manipulation of the spine to correct subluxation. 
Enrollees must pay a $20 copay for each Medicare-covered chiropractic service for spinal manipulation. 
Routine chiropractic visits include up to 6 supplemental routine visits every year. Routine services provide 
coverage for spinal manipulation once the therapeutic goals are reached, or met maximum medical 
improvement. You can find this information on page 71 of the plan's 2020 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 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). 
 
Local Coverage Determination (LCD): Polysomnography and Sleep Testing (L33405) -  For Positive Airway 
Pressure (PAP) titration, a split-night study (initial diagnostic polysomnogram followed by PAP titration during 
polysomnography on the same night) is an alternative to one full night of diagnostic polysomnography, 
followed by a second night of titration for the treatment of obstructive sleep apnea (OSA) if the following 
criteria are met:  
 
A positive test for OSA is established if either of the following criteria using the Apnea-Hypopnea Index (AHI) 
or Respiratory Disturbance Index (RDI) is met:  
 
    AHI or RDI greater than or equal to 15 events per hour, or 
    AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented 
symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented 
hypertension, ischemic heart disease, or history of 
    There are at least three hours for PAP titration prior to the end of the test. 
 
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 $45 copayment for consultation, diagnosis, and treatment by a specialist. 
The Plan contract also says that enrollees must pay a $30 copayment for Medicare-covered non-radiological 
diagnostic services. You can find this information on pages 4-29 to 4-32 and pages 4-39 to 4-43 of the Plan's 
2020 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 must report services correctly. Procedures should be reported with the CPT code 
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative 
Manual, Chapter I(A). 
 
The rules say that the rate, facility or non-facility that a physician service is paid under the MPFS is determined 
by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-
to-face encounter with the physician, non-physician practitioner (NPP) or other supplier. In general, the POS 
code reflects the actual place where the beneficiary receives the face-to-face service and determines whether 
the facility or non-facility payment rate is paid. You can see this in the Medicare Claims Processing Manual 
Chapter 12 Section 20.4.2. 
 
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.  You 
can find this rule at Medicare Claims Processing Manual Ch. 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 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 $0 copayment for days 1-20 and a $160 copayment for days 21-100 for 
SNF care. You can find this information in Chapter 4 on page 97 of the Plan's 2020 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 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). 
 
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 also says that there $500 deductible for out of network services for Physician/practitioner services, 
including doctor's office visits. You can find this information on page 55 of the Plan's 2020 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 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 $40 copayment for each basic imaging service (e.g. general x-rays or 
ultrasound). You can find this information on page 91 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 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 SSA, Section 1862(a)(12) and 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 that services are covered when medically necessary and based on the benefit limitations and 
clinical criteria described in the Plan's Office Manager Reference Manual (ORM). You can find this 
information on page 66 of the Plan's 2020 Evidence of Coverage. 
 
The ORM says that the placement of a fixed prosthetic appliance will only be considered for the anterior 
segment of the mouth in those exceptional cases where there is a documented physical or neurological disorder 
that would preclude placement of a removable prosthesis, or in those cases requiring cleft palate stabilization. 
In cases other than for cleft palate stabilization, treatment would generally be limited to replacement of a single 
maxillary anterior tooth or replacement of two adjacent mandibular teeth. For a patient whose pulpal anatomy 
allows crown preparation of abutment teeth without pulp exposure, the construction of a conventional fixed 
bridge will be approved only for the replacement of a single missing maxillary anterior tooth or two adjacent 
missing mandibular anterior teeth. You can find this information on page 131 of the Plan's 2020 ORM.
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 $260 copayment for each covered, one-way ambulance trip by ground or 
water. You can find this information in Chapter 4 on pages 52 to 53 of the Plan's 2020 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 state that MACs subject all line items for the same beneficiary, same NPI, and same date of service to 
NCCI edits.  
 
All line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI 
procedure-to-procedure (PTP) edits. If the CCMI of a PTP edit is "0", the column two code is not eligible for 
payment even if an NCCI-associated modifier is appropriately appended to one of the codes. If the CCMI of a 
PTP edit is "1", the edit may be bypassed and the column two code of the edit may be eligible for payment if 
an NCCI-associated modifier is appropriately appended to one of the codes. If the two codes of a code pair edit 
have the same NCCI-associated anatomic modifiers, the edit should not be bypassed unless an additional 
NCCI-associated modifier is appended to one of the codes indicating the reason to bypass the edit.  
 
The use of modifiers that are not NCCI-associated modifiers shall not bypass an NCCI PTP edit. NCCI-
associated modifiers are the following: 
 
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI  
Global surgery modifiers: 24, 25, 57, 58, 78, 79 
Other modifiers: 27, 59, 91, XE, XS, XP, XU  
 
You can find this information in Medicare Claims Processing Manual Chapter 23, Section 20.9.1.1. 
 
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.