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 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 visits by the same physician on the same day as a minor surgery or endoscopy are included in 
the payment for the procedure, unless a significant, separately identifiable service is also performed. Modifier 
"-25" is used to facilitate billing of evaluation and management services on the day of a procedure for which 
separate payment may be made. It is used to report a significant, separately identifiable evaluation and 
management service by same physician on the day of a procedure. You can find this rule in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 12, Sections 40.1(C) and 40.2.A(8). 
 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 an Intrapulmonary Percussive Ventilator (IPV) is a mechanized form of chest physical 
therapy. Instead of a therapist clapping or slapping the patient's chest wall, the IPV delivers mini bursts (more 
than 200 per minute) of respiratory gasses to the lungs via a mouthpiece. Its intended purpose is to mobilize 
endobronchial secretions and diffuse patchy atelectasis. The patient controls variables such as inspiratory time, 
peak pressure and delivery rates. 
 
Studies do not demonstrate any advantage of IPV over that achieved with good pulmonary care in the hospital 
environment and there are no studies in the home setting. There are no data to support the effectiveness of the 
device. Therefore, IPV in the home setting is not covered. 
 
You can find these rules in the National Coverage Determination (NCD) Intrapulmonary Percussive Ventilator 
(IPV) 240.5. 
 
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 state that according to the American Society of Plastic and Reconstructive Surgeons, the specialty of 
plastic surgery includes reconstructive and cosmetic procedures: 
 
Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, 
developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally 
performed to improve function, may also be done to approximate a normal appearance, and may be covered as 
surgery is considered reconstructive in nature. 
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's 
appearance and self-esteem. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, 
Chapter 16: Section 120 for detailed information. 
 Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no 
functional impairment present. However, some congenital, acquired, traumatic or developmental 
anomalies may not result in functional impairment, but are so severely disfiguring (e.g. but not limited 
to severe burns or repair of the face following a serious automobile accident) as to merit consideration 
for corrective surgery. 
 Treatment of complications arising from cosmetic surgery will be considered reasonable and necessary 
as long as infection, hemorrhage or other serious documented medical complication occurs, and the 
beneficiary has been officially discharged from the facility. 
Per the Medicare Benefit Policy Manual cosmetic surgery or expenses incurred in connection with such 
surgery, for the sole purpose of improving ones appearance, is not covered. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L39051: Cosmetic and 
Reconstructive Surgery. 
 
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 Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when 
all the following requirements are met: 
1. Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
between the upper level of the iliac crests and the gluteal fold, AND 
2. Low back pain duration of at least three (3) months, AND 
3. Low back pain below L5 without radiculopathy, AND 
4. Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal 
stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, 
pseudoarthrosis, or pain related to spinal instrumentation), AND 
5. At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or 
Posterior Shear, SI Compression, SI Distraction and Yeoman Tests,
3,4
 AND 
6. Low back pain persists despite a minimum of four weeks of conservative therapies.
5
 
You can find this information in the Local Coverage Determination (LCD): Sacroiliac Joint Injections and 
Procedures (L39455). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on pages 183 to 184 of the Plans 2023 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b).  
 
The rules say subluxation may be shown by x-ray or physical exam. 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 240.1.2. 
 
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 the only covered chiropractic service is adjustments of the spine to correct alignment. You 
can find this information on page 59 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 genetic testing procedures submitted under code 81232 is unlikely to impact therapeutic 
decision-making in the clinical management of the patient and will be denied automatically as not medically 
necessary. You can find this information in 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 say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and 
charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only 
those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically 
necessary (including non-preferred) DME products or brands. You can find this information in the Centers for 
Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed Care Manual 
Chapter 4, 10.12.2. 
 
The rules say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations, premiums and cost-sharing, and any other conditions 
associated with receipt or use of benefits. 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 e the only covered brands of blood glucose monitors and test strips: ACCU-CHEK 
manufactured by Roche, or Trividia products sometimes packaged under your pharmacys name. You can find 
this information in Chapter 4 on pages 53-54 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 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 SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable and 
necessary. You can find this rule at the Medicare Local Coverage Determination (LCD) L39475: Sacroiliac 
Joint Injections and Procedures. 
 
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 say that screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a benefit and are not covered. Similarly, the costs of 
tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly effects the 
management of the patient may not be reimbursed. You can find this rule in the Local Coverage Determination 
for Molecular Pathology Procedures, L34519. 
 
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 repeat epidural steroid injection (ESI) is covered when the first injection directly and 
significantly provided improvement of the condition being treated and 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 3 months.  
You can find this information at Local Coverage Determination (LCD)- Epidural Steroid Injections for Pain 
Management (L38994). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules 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 services of other physicians, except where the surgeon and the other physician(s) agree on 
the transfer of care, are not included in the global surgical package. These services may be paid for separately. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.1(B). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioner's records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
The rules say that Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of 
the following qualified skilled services:  
 
1. Skilled nursing care;  
2. Physical therapy;  
3. Occupational therapy; or  4. Speech pathology services.  
 
HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, 
home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 
and 409.45. 
 
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. This benefit for supplemental 
dental coverage is limited to $3,000 annually. You can find this information on page 73 of the Plan's 2023 
Evidence of Coverage (EOC).