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 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 modifier -59 is used to indicate a distinct procedural service. This may represent a different 
session or patient encounter, different procedure or surgery, different site, or organ system, separate 
incision/excision, or separate injury. You can find this rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, National Correct Coding Initiative Policy Manual, Chapter 1, Section E(d). 
 
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. 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.
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 pages 61-76 of the Plan's 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 state that acupuncture for stimulation of auricular points is not a covered Medicare benefit. You can 
find this rule in Local Coverage Article: Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-
Acupuncture Device) (A55240). 
 
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 percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for painful, debilitating, 
osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical 
medical management (e.g. narcotic and/or non- narcotic medication, physical therapy modalities) with and 
without methods of immobility (e.g. rest, bracing). You can find this information in Local Coverage 
Determination (LCD): Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture 
(VCF) (L35130). 
 
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 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, 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 in Chapter 3 on page 33-34 of the 
Plan's 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 state that SNFs and hospital swing bed providers are required to report certain data elements, 
including Revenue Code 0022. This code indicates that this claim is being paid under the SNF Prospective 
Payment System (PPS). This revenue code can appear on a claim as often as necessary to indicate different 
Health Insurance Prospective Payment System (HIPPS) Rate Code(s) and assessment periods. The Healthcare 
Common Procedure Coding System (HCPCS)/Rates field must contain a 5-digit HIPPS Code. You can find 
this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 6, Section 30. 
 
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 MolDX Team has completed the Afirma assessment and determined that the test meets 
criteria for analytical and clinical validity, and clinical utility as a reasonable and necessary Medicare benefit. 
Effective 10/01/2015, MolDX will reimburse Afirma services for patients with the following conditions 
(patient must have 1 and 2): 
 
1. Patients with one of more thyroid nodules with a history or characteristics suggesting malignancy such as: 
 
-Nodule growth over time 
-Family history of thyroid cancer 
-Hoarseness, difficulty swallowing or breathing 
-History of exposure to ionizing radiation 
-Hard nodule compared with rest of gland consistency 
-Presence of cervical adenopathy 
 
2. Have an indeterminate follicular pathology on fine needle aspiration 
 
You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: MolDX: Afirma Assay by 
Veracyte (A54356). 
 
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 modifier XU is a valid modifier. This modifier gives greater reporting specificity in 
situations where you used modifier 59 previously. Modifier XU is defined as - "Unusual Non-Overlapping 
Service, the use of a service that is distinct because it does not overlap usual components of the main service." 
You can find this rule in the in the Medicare Learning Network (MLN) Fact Sheet - Proper Use of Modifiers 
59, XE, XP, XS, XU.. 
 
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 there may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts, 
skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts 
is medically appropriate. Medicare will, therefore, consider their removal as medically necessary, and not 
cosmetic, if one or more of the following conditions are presented and clearly documented in the medical 
record: 
- Bleeding; 
- Intense itching; 
- Pain; 
- Change in physical appearance (reddening or pigmentary change); 
- Recent enlargement; 
- Increase in the number of lesions; 
- Physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.; 
- Lesion obstructs an orifice; 
- Lesion clinically restricts eye function. For example: 
a. Lesion restricts eyelid function; 
b. lesion causes misdirection of eyelashes or eyelid; 
c. lesion restricts lacrimal puncta and interferes with tear flow; 
d. lesion touches globe; 
- Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration 
based on lesion appearance; 
- A prior biopsy suggests or is indicative of lesion malignancy; 
- The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation 
that such trauma has, in fact, occurred; 
- Recent enlargement, history of rupture or previous inflammation, or location subjects patient to risk of 
rupture of epidermal inclusion (sebaceous) cyst. 
- Wart removals will be covered under the guidelines above. In addition, wart destruction will be covered 
when any of the following clinical circumstances are present: 
a. Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion 
virus shedding; b. Warts showing evidence of spread from one body area to another, particularly in 
immunosuppressed patients or warts of recent origin in an immunocompromised patients; 
c. Lesions are condyloma acuminata or molluscum contagiosum; 
d. Cervical dysplasia or pregnancy is associated with genital warts. 
You can find this information in Local Coverage Determination (LCD): Removal of Benign Skin Lesions 
(L34200). 
 
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 American Society for Radiation Oncology (ASTRO) intensity-modulated radiation 
therapy (IMRT) policy outlines clinical scenarios that would not typically support the use of IMRT. This 
includes palliative treatment of metastatic disease where the prescribed dose does not approach normal tissue 
tolerances. 
 
You can find these rules in Local Coverage Determination (LCD) Intensity Modulated Radiation Therapy 
(IMRT) (L36711). 
 
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 Guidance Manual, Section 50.12.1. 
 
The rules say that a type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! 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 information in the ICD-10-CM Official 
Guidelines for Coding and Reporting, Section I. Conventions, general coding guidelines and chapter specific 
guidelines. 
 
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 health plans, physicians, hospitals, and other health care providers must comply with the 
Official International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding 
Guidelines. 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 10.  
 
The rules state that a type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! 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 information in the ICD-10-CM Official 
Guidelines for Coding and Reporting, Section I. Conventions, general coding guidelines and chapter specific 
guidelines.  
 
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 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, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules also state that molecular pathology procedures have broad clinical and research applications. The 
following examples of applications may not be relevant to a Medicare beneficiary or may not meet a Medicare 
benefit category and/or reasonable and necessary threshold for coverage. Such examples include Genetic 
Testing and Genetic Counseling (when applicable) for carrier screening. You can find this rule in Local 
Coverage Determination (LCD): Molecular Pathology Procedures (L35000). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. This benefit does not include D2950. You can find this information on page 85 of the Plan's 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 Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a 4100 
deductible. This also includes a 50% coinsurance for extractions. This benefit does not include anesthesia. You 
can find this information on pages 65-68 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 Coverage Requirements 
 
Medicare will reimburse for necessary components of decongestive treatment when the medical record 
supports 
 
 A diagnosis of lymphedema (not tissue edema due to other etiologies e.g., chronic venous insufficiency, 
congestive heart failure, acute infection). 
 Recent changes in the patients condition 
 Prior unsuccessful therapies (e.g., elevation, bandaging, diuresis) reported to justify the need for skilled 
services. 
 Services were provided by a qualified clinician (i.e., physician, non-physician practitioner (NPP), qualified 
therapist, or appropriately supervised therapist assistant). 
 Services must be under accepted standards of medical practice and considered to be specific and effective 
treatment for the patients condition. 
  
 You can find this information in Medicare's Local Coverage Article - Billing and Coding: Lymphedema 
Decongestive Treatment (A52959). 
 
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 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 24 one-way trips are covered each year (limited to ground transportation only). You are 
responsible for any costs over the trip limit. You can find this information on pages 89-90 of the Plans 2023 
Evidence of Coverage (EOC).