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 section 1128 of the Social Security Act provides the authority to Medicare to exclude various 
health care providers from receiving payment under Medicare. When an exclusion is imposed, no payment is 
made to anyone for any items or services in any capacity furnished, ordered, or prescribed by an excluded party 
under the Medicare, Medicaid, and all federal health care programs. In addition, no payment is made to any 
business or facility, e.g., a hospital, that submits claims for payment of items or services provided, ordered, 
prescribed, or referred by an excluded party. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 4, 
Section 4.19.2. 
 
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.
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 Type I PSG is covered when used to aid the diagnosis of Obstructive Sleep Apnea (OSA) 
in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab 
facility. You can find this information in the National Coverage Determination (NCD) for Sleep Testing for 
Obstructive Sleep Apnea (OSA) (240.4.1). 
 
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 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 physician/practitioner services, 
including doctors office visits, for services obtained from a specialist, or under certain circumstances, 
treatment by a nurse practitioner or physicians assistant or other non-physician. You can find this information 
on pages 4-55 and 4-56 of the Plans 2021 Evidence of Coverage. The Plan contract also says that enrollees 
must pay a $20 copayment for other outpatient diagnostic tests -non-radiological diagnostic services. You can 
find this information on page 4-43 of the Plan's 2021 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 panels with >5 respiratory pathogens performed in the Part B outpatient setting are 
considered not medically reasonable and necessary. You can find this information in Local Coverage 
Determination (LCD): Respiratory Pathogen Panel Testing (L38918). 
 
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 one of the three major functions provided by the IOCE is the application of edit(s) to identify 
errors. Each edit is unique, as it directly links the reason the edit is returned, any related information at the line 
or claim level, and the action required indicated by the edit disposition. A Line Item Denial (LID) indicates 
there are one or more edits present that cause one or more individual line items to be denied. A line item denial 
means that the claim can be processed for payment with some line items denied for payment. A line Item 
Rejection (LIR) indicates there are one or more edits present that cause one or more individual line items to be 
rejected. A line item rejection means that the claim can be processed for payment with some line items rejected 
for payment.  
 
A code edit of 9 means services are non-covered under any Medicare outpatient benefit, for reasons other than 
statutory exclusion. This is a line item denial. A code edit of 47 indicates that a service is not separately 
payable. Edit 47 is assigned to all lines with a status indicator of N. This is a line item rejection. A code edit 15 
is in effect for dates August 1, 2020, to June 30, 2008. You can find this rule in the Integrated Outpatient Code 
Edit (IOCE) for the Centers for Medicare and Medicaid Services (CMS) Specifications, Volume 23.1, Sections 
6.1 and 6.2. 
 
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.
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 all molecular diagnostic test (MDT) services must include an identifier as additional claim 
documentation. Test providers must receive an identifier specific to the applicable test and submit the test 
assigned identifier with the claim for reimbursement. The assigned identifier will provide a crosswalk between 
the tests associated detail information on file and the submitted claim detail line(s) required to adjudicate each 
tests claim. The unique identifier limits the need to submit the required additional information about the test 
on each claim. You can find this information in the Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) (L36256). 
 
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 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. 
 
The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than the close 
of the period ending 1 calendar year after the date of service. You can find this rule at 42 CFR Section 
424.44(a). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. You can find 
this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Chapter 1, Section 280.6. 
 
The rules say that, at a minimum, re-assessments conducted for a trial must include detailed measurements, 
obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion 
of the various trials and therapy, with bilateral comparisons where appropriate. You can find this information in 
the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).  
 
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 molecular diagnostic tests are subject to coverage determinations made through the MolDX 
Program. You can find this information in Local Coverage Determination (LCD): MolDX: Molecular 
Diagnostic Tests (MDT) (L36021). 
 
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 supplemental plethysmography, contrast venography, venous pressure measurements, 
intravascular ultrasound (IVUS), computed tomography (CT) venography, or magnetic resonance (MR) 
venography may be relevant to the plan of care in patients with severe or unusual presentations of venous 
disease in which there is possible concurrent involvement of pelvic veins or arterial-venous malformations or 
fistulae. Indications for these more extensive procedures should be documented in the plan of care. You can 
find this rule in the Local Coverage Determination (LCD) - Treatment of Chronic Venous Insufficiency of the 
Lower Extremities (L34924) - Effective December 27, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Urine drug testing (UDT) provides objective information to assist clinicians in identifying 
the presence or absence of drugs or drug classes in the body and making treatment decisions. A presumptive 
drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. 
However, urine is the best specimen for presumptive screening, as blood is relatively insensitive for many 
common drugs, including psychotropic agents, opioids, and stimulants. 
 
Blanket orders and routine standing orders for all patients in a physician's practice are not reasonable and 
necessary. You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage 
Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L35006). 
 
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/B MACs (B) apply the national definition of a global surgical package to all procedures 
with the appropriate entry in Field 16 of the MFSDB.  
 
The Medicare approved amount for these procedures includes payment for preoperative visits after the decision 
is made to operate beginning with the day before the day of surgery for major procedures and the day of 
surgery for minor procedures. 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.  
 
Modifiers were established to simplify billing for visits and other procedures which are furnished during the 
postoperative period of a surgical procedure, but which are not included in the payment for the surgical 
procedure. Modifier -79 reports an unrelated procedure by the same physician during a postoperative period. 
The physician may need to indicate that the performance of a procedure or service during a postoperative 
period was unrelated to the original procedure 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 40.2 
 
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.
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 one to two levels, either unilateral or bilateral, are allowed per session per spine region. The 
need for a three or four-level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. A session is a time period, which includes all 
procedures (i.e., medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA 
ablations that are performed during the same day. You can find this information in Local Coverage 
Determination (LCD): Facet Joint Interventions for Pain Management (L35936). 
 
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 specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(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.
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 $60 copayment for outpatient diagnostic tests and therapeutic services 
and supplies. You can find this information on page 99 of the Plan's 2022 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 a Type I PSG is covered when used to aid the diagnosis of Obstructive Sleep Apnea (OSA) 
in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab 
facility, and a Type II or Type III sleep testing devices are covered when used to aid the diagnosis of OSA in 
beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a 
sleep lab facility or attended in a sleep lab facility. You can find this information in the National Coverage 
Determination (NCD) for Sleep Testing for Obstructive Sleep Apnea (OSA) (240.4.1). 
 
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 state that Medicare covers one pair of conventional eyeglasses or conventional contact lenses 
furnished after each cataract surgery with insertion of an intraocular lens. You can find this information in the 
Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-02, Medicare 
Benefit Policy Manual, Chapter 15, Section 120. 
 
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 $195 copayment for all other services furnished at a hospital outpatient 
facility. You can find this information in Chapter 4 on page 87 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 reporting the urea reduction ratio (URR) for end stage renal disease (ESRD) hemodialysis 
claims all hemodialysis claims must indicate the most recent URR for the dialysis patient. Code all claims 
using HCPCS code 90999 along with the appropriate G modifier. 
 
For services beginning January 1, 2003, and after, if the modifier is not present, A/B/MACs (A) must return the 
claim to the provider for the appropriate modifier. Effective April, 2007 due to the requirement of line item 
billing, at least one revenue code line for hemodialysis on the claim must contain one of the URR modifiers 
shown above. The URR modifier is not required on every hemodialysis line on the claim. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare 
Claims Processing Manual, Chapter 8, Section 50.9. 
 
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 Medicare pays for home health care services under a prospective payment system (HH PPS). 
You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 10, Section 40.1. 
 
The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. You can find this rule in the Centers 
for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing 
Manual, Chapter 1, Section 80.3.1. 
 
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.