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 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 TENS is not reasonable and necessary for the treatment of CLBP under section 
1862(a)(1)(A) of the Act. You can find this rule in the National Coverage Determination (NCD) 
Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) 160.27. 
 
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 submission of claims using individual gene CPT codes, when either 5-50 or >50 gene 
panels are ordered, is considered incorrect coding. Correct coding requires that when a panel code is ordered, it 
should be billed, rather than the individual gene codes. CPT code 81445 or 81450 should be billed when 5 to 
50 genes are ordered. CPT code 81455 should be billed when 51 or greater genes are ordered for molecular 
biomarkers. When a panel with greater than one or less than five genes is ordered, use the corresponding 
existing panel CPT code or CPT code 81479 if none exists. You can find this information in the 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 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 Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis 
and treatment of chronic pain in patients who meet ALL the following criteria: 
1.Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2.Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3.Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
4.There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
You can find this information in the Local Coverage Determination LCD: Facet Joint Interventions for Pain 
Management (L38803). 
 
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 submission of claims using individual gene CPT codes, when either 5-50 or >50 gene 
panels are ordered, is considered incorrect coding. Correct coding requires that when a panel code is ordered, it 
should be billed, rather than the individual gene codes. CPT code 81445 or 81450 should be billed when 5 to 
50 genes are ordered. CPT code 81455 should be billed when 51 or greater genes are ordered for molecular 
biomarkers. When a panel with greater than one or less than five genes is ordered, use the corresponding 
existing panel CPT code or CPT code 81479 if none exists. You can find this information in the Local 
Coverage Article (LCA): Billing and Coding: Molecular Pathology Procedures (A56199). 
 
The rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of 
Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face 
service. For example, if the physicians face-to-face encounter with a patient occurs in the office, the correct 
POS code on the claim, in general, reflects the 2-digit POS code 11 for office. If an independent lab bills, the 
place where the sample was taken is shown. You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual Chapter 
26, Section 10.6. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $30 copayment for in-network non-radiological diagnostic services, 
including EKGs. 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 say that Medicare pays for ambulance services that meet certain origin and destination requirements. 
In order to meet this requirement, the ambulance supplier must transport the patient for whom the emergency 
call was placed. If an ambulance responds to a call but does not transport the person for whom the call 
was placed, Medicare does not pay for the service. You can find this rule at 42 CFR Section 410.40(f) and in 
the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 10, Section 10. 
 
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 pay for an IRF admission when the services are reasonable and medically 
necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing 
rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of 
the therapies must be physical therapy or occupational therapy. The patient must need and be expected to 
actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive 
rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per 
week. The patient does not need to be expected to achieve complete independence in self-care nor be expected 
to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation 
physician. The physician must see the patient at least three days per week throughout the stay. You can find 
these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622. 
 
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 claims processing systems contain edits which identify exact duplicate claims and 
suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected. Some claims that 
appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances 
of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers 
of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may 
appear to be duplicates, but, in fact, are not. You can find this rule in the Centers for Medicare and Medicaid 
Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, 
Section 120.1. 
 
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.
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 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. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 41 of the Plan's 2022 
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 radiofrequency ablation is covered after the patient has had at least two (2) medically 
reasonable and necessary  
diagnostic Medial Branch Blocks, with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain. This rule can be found in Medicare Local Coverage Determination (LCD): Facet Joint 
Interventions for Pain Management (L35936). 
 
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 only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. You can find this rule at 42 CFR Section 410.21(b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that for chiropractic care, the Plan only covers manual manipulation of the spine to correct 
subluxation. You can see this on page 50 of the Plan 2021 Evidence of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the 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 lists the dental 
services that are covered. Abutment supported crown is not listed and therefore is not a covered service. You 
can find this information on page 109 of the Plans 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 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 $325 copayment for outpatient surgery. You can find this information 
on page 4-38 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 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 the physician must clearly document, in the medical record, his or her intent that the test be 
performed. An order is a communication from the treating physician/practitioner requesting that a diagnostic 
test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a 
particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by 
the treating physician/practitioner (e.g., if test X is negative, then perform test Y). You can find this rule in 
Medicare Benefit Policy Manual; Chapter 15, Section 80.6. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say 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 Medicare Claims Processing Manual, Chapter 23, Section 10. 
 
The rules also say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes 
for both the left and right side. If the side is not identified in the medical record, assign the code for the 
unspecified side. 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 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. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 14 of the 2021 Evidence 
of Coverage.
Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
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 $20 copayment for non-radiological diagnostic services, including 
EKGs. You can find this information on page 4-32 of the Plan's 2021 Evidence of Coverage (EOC).