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 when a physician/practitioner furnishes services to a registered inpatient, payment is made 
under the Physician Fee Schedule (PFS) at the facility rate. To that end, a physician/practitioner/supplier 
furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital 
place of service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face 
encounter. You can find this in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Medicare Claims Processing Manual, Chapter 26, Section 10.5 under heading, "Special Considerations for 
Services Furnished to Registered Inpatients". 
 
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 following are examples of wound care items which are non-covered under the surgical 
dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): 
 Skin sealants or barriers (A6250) 
 Wound cleansers (A6260) or irrigating solutions 
 Solutions used to moisten gauze (e.g., saline) 
 Silicone gel sheets (A6025) 
 Topical antiseptics 
 Topical antibiotics 
 Enzymatic debriding agents 
 Gauze or other dressings used to cleanse or debride a wound but not left on the wound 
 First-aid type adhesive bandage (A6413) 
 Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which 
requires a prescription 
 Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, 
A6540, A6541, A6544, A6549) 
 Surgical stockings (A4490, A4495, A4500, A4510) 
 Non-elastic binder for an extremity (A4465)  Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of 
wounds addressed in the Surgical Dressings policy. 
These dressings are noncovered under the surgical dressing benefit. 
Claims for products that are not able to be used as a primary or secondary dressing on a qualifying wound of 
the skin or that are composed of materials that do not serve a therapeutic or protective function will be denied 
as statutorily non-covered, no benefit. You can find this rule in Local Coverage Article Surgical Dressings - 
Policy Article A54563. 
 
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 to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
 
1. The beneficiary has diabetes mellitus; and 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has 
sufficient training using the CGM prescribed as evidenced by providing a prescription; and 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; and 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the 
criteria below: 
   A. The beneficiary is insulin-treated; or 
   B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
following: 
      -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust  
            medication(s) and/or modify the diabetes treatment plan; or 
      -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state 
requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-
approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-
(4) above are met.  
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
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). 
 
Medicare rules say that an Implantable Loop Recorder (ILR) is a type of pre-symptom Memory Loop Recorder 
(MLR) which is implanted subcutaneously in a patient's upper left chest, where it may remain implanted for 
many months. An ILR is used when syncope is thought to be cardiac-related but is too infrequent to be detected 
by either a Holter monitor or a traditional pre-symptom MLR. You can find this information in the Centers for 
Medicare and Medicaid Service, Internet-Only Manual, Publication 100-03, Medicare National Coverage 
Determination (NCD): Electrocardiographic Services (20.15). 
 
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 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 evaluation and management services on the day before major surgery or on the day of major 
surgery that result in the initial decision to perform the surgery are not included in the global surgery payment 
for the major surgery and, therefore, may be billed and paid separately. If evaluation and management services 
occur on the day of surgery, the physician bills using modifier "-57," not "-25". 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 40.2.A(4). 
 
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 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 31 to 35 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 the Centers for Medicare and Medicaid Service (CMS) has established units of service edits 
referred to as Medically Unlikely Edits (MUEs). An MUE for a Healthcare Common Procedure Coding System 
(HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of service under most 
circumstances allowable by the same provider for the same enrollee on the same date of service. Claims 
submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.   
 
Beginning on April 1, 2013, CMS introduced the MUE Adjudication Indicator (MAI) to differentiate between 
types of MUEs. If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code 
on separate lines of the claim. MUEs for codes with an MAI of 2 are absolute date of service edits. These are 
per day edits based on policy. Codes with an MAI of 2 have been rigorously reviewed and vetted within 
CMS and obtain this MAI designation because units of service on the same date of service (DOS) in excess of 
the MUE value would be considered impossible because it was contrary to statute, regulation, or subregulatory 
guidance. 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(V). 
 
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 National Correct Coding Initiative (NCCI) was developed to prevent inappropriate 
payment of services that should not be reported together. NCCI edits are organized in a Column I/Column 2 
table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit 
pair, only the Column 1 code is payable. For edits with a modifier indicator of 0, the Column 2 code cannot be 
paid regardless of whether a modifier is used. You can find this in the NCCI Manual, Chapter I. 
 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 Percutaneous vertebroplasty 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 with and without methods of immobility. 
        1. Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria 
are met: 
            A. Acute or subacute osteoporotic VCF (T1 L5), based on symptom onset, and documented by 
advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/computed tomography 
(CT) uptake and 
            B. The beneficiary is symptomatic and is hospitalized with severe pain or is non-hospitalized with 
moderate to severe pain despite optimal non-surgical management with one of the following: 
                a. Worsening Pain or 
                b. Stable to improved pain when 2 or more of the following are present: 
                    -Progression of vertebral body height loss 
                    -Greater than 25% vertebral body height reduction 
                    -Kyphotic deformity 
                    -Severe impact of VCF on daily functioning  
 
You can find this information in Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmnentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
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 says that thyroid function tests are used to define hyper function, euthyroidism, or hypofunction of 
thyroid disease. Thyroid testing may be reasonable and necessary to: 
 
    -Distinguish between primary and secondary hypothyroidism; 
    -Confirm or rule out primary hypothyroidism; 
    -Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer); 
    -Monitor drug therapy in patients with primary hypothyroidism; 
    -Confirm or rule out primary hyperthyroidism; and 
    -Monitor therapy in patients with hyperthyroidism. 
 
You can find this information in National Coverage Determination (NCD): Thyroid Testing (190.22). 
 
The rules also 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. 
 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 4% coinsurance for out-of-network outpatient surgery. You can find this 
information on page(s) 4-43 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 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. While the Plan offers a Point-of-Service (POS) benefit for 
coverage of out-of-network services, this benefit only applies to dental services. You can find this information 
on pages 31 to 32 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. 
 
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 cervical and vaginal cancer screening is covered for all women: Pap tests and pelvic 
exams are covered once every 24 months You can find this information on page 6 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 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 Schnur sliding scale is an evaluation method for physicians to use on individuals 
considering breast reduction surgery. If the individual's body surface area and weight of breast tissue removed 
fall above the 22nd percentile, then the surgery is considered medically reasonable and necessary with the 
appropriate criteria.
5
 The scale abbreviated below allows a rough estimate of the minimal amount of soft tissue 
to be removed to justify surgery to alleviate symptoms based on body surface area; breast tissue may be 
removed from the other breast in order to achieve symmetry. 
SCHNUR SCALE: 
Body Surface 
Area (m
2
) 
Average grams 
of tissue to be 
removed per 
breast 
1.40-1.90 324-780g 
1.91-2.00 795-935g 
2.01-2.30 950-1000g 
BSA>2.31 >1000g 
 
In a study, based on questionnaire responses from women who had undergone reduction mammoplasty, Schnur 
and colleagues (1997)
35
 reported that in properly selected individuals, reduction mammaplasty is a safe and 
effective procedure for relieving or improving symptoms related to symptomatic macromastia. The medical literature supports an approach based upon the measurement of body surface area such as the Schnur scale. 
Keeping with accepted medical opinion and medical evidence, the use of the Schnur scale is noted to ensure 
that an adequate amount of breast tissue be removed in order to maximize the probability of symptomatic 
relief. Additionally, specialty consensus opinion agrees that breasts are considered paired organs, and it is not 
possible to definitively relate symptoms to one breast or the other. Therefore, bilateral breast reduction 
mammaplasty may be considered appropriate if the amount of breast tissue anticipated for removal from at 
least one breast meets the minimum amount (weight) per the Schnur scale and all other criteria are met. 
 
Local Coverage Determination: Cosmetic and Reconstructive Surgery (L38914). 
 
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 code A9279 (monitoring feature) is non-covered. This rule is found in Local Coverage 
Article: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea  Policy 
Article (A52467). 
 
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.